Provider Demographics
NPI:1740316728
Name:ST JOHNS CLINIC INC
Entity type:Organization
Organization Name:ST JOHNS CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DONN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-829-4264
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:90 GRAVEL ST
Practice Address - Street 2:
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-1601
Practice Address - Country:US
Practice Address - Phone:417-847-6045
Practice Address - Fax:417-847-6049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4E21207Q00000X
MO261QR1300X
MO104182363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO598833101Medicaid
MO268923Medicare Oscar/Certification