Provider Demographics
NPI:1255388039
Name:ST. JOHN'S MEDICAL GROUP
Entity type:Organization
Organization Name:ST. JOHN'S MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-627-8930
Mailing Address - Street 1:1701 W 26TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1513
Mailing Address - Country:US
Mailing Address - Phone:417-627-8967
Mailing Address - Fax:417-627-8920
Practice Address - Street 1:2711 S ROUSE ST
Practice Address - Street 2:SUITE C
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6620
Practice Address - Country:US
Practice Address - Phone:417-627-8967
Practice Address - Fax:417-627-8951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110805Medicare ID - Type UnspecifiedKS GROUP NUMBER