Provider Demographics
NPI:1255388849
Name:ST JOHNS EXPRESS CARE
Entity type:Organization
Organization Name:ST JOHNS EXPRESS CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:EBMEIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-625-2878
Mailing Address - Street 1:PO BOX 1240
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64802-1240
Mailing Address - Country:US
Mailing Address - Phone:417-625-2878
Mailing Address - Fax:417-625-2807
Practice Address - Street 1:1313 S RANGELINE RD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-5588
Practice Address - Country:US
Practice Address - Phone:417-625-2878
Practice Address - Fax:417-625-2807
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOHNS MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2008-08-25
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
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5115270002OtherDMERC