Provider Demographics
NPI:1841240546
Name:ST JOHNS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:ST JOHNS REGIONAL MEDICAL CENTER
Other - Org Name:21ST CENTURY ANESTHESIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARALIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-781-2727
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64802-0760
Mailing Address - Country:US
Mailing Address - Phone:417-624-3040
Mailing Address - Fax:
Practice Address - Street 1:2727 MCCLELLAND BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1626
Practice Address - Country:US
Practice Address - Phone:417-781-2727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Multi-Specialty
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505098509Medicaid
MO108602AOtherBCBS
CG9560OtherRAILROAD MEDICARE
KS100000880EMedicaid
OK100693700MMedicaid
KS100000880EMedicaid