Provider Demographics
NPI:1841515806
Name:JEFFERSON REGIONAL OUTPATIENT FACILITIES, LLC
Entity type:Organization
Organization Name:JEFFERSON REGIONAL OUTPATIENT FACILITIES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-251-1952
Mailing Address - Street 1:660A S TRUMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-2235
Mailing Address - Country:US
Mailing Address - Phone:636-933-1669
Mailing Address - Fax:636-933-1203
Practice Address - Street 1:660A S TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-2235
Practice Address - Country:US
Practice Address - Phone:636-933-1669
Practice Address - Fax:636-933-1203
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-02
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2477Medicare PIN