Provider Demographics
NPI:1831270164
Name:SAINT JOHN'S HEALTH SYSTEM
Entity type:Organization
Organization Name:SAINT JOHN'S HEALTH SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-646-8105
Mailing Address - Street 1:4925 S SCATTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013-2911
Mailing Address - Country:US
Mailing Address - Phone:765-646-6331
Mailing Address - Fax:765-641-2593
Practice Address - Street 1:4925 S SCATTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-2911
Practice Address - Country:US
Practice Address - Phone:765-646-6331
Practice Address - Fax:765-641-2593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN509760Medicare ID - Type Unspecified