MEDICARE: ST. JOHN'S MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1376579565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JOHN'S MEDICAL GROUP

Provider Business Mailing Address
First Line	:	2631 CUNNINGHAM AVE
Second Line	:	SUITE A
City	:	JOPLIN
State	:	MO
Zip	:	64804-1543
Country	:	US
Telephone Number	:	417-627-8967
Fax Number	:	417-627-8951

Provider Business Practice Location Address
First Line	:	307 N HOSPITAL DR
Second Line	:	SUITE 5
City	:	GIRARD
State	:	KS
Zip	:	66743-2014
Country	:	US
Telephone Number	:	620-724-4659
Fax Number	:	620-724-6955

Authorized Official
Title or Position	:	COO
Name	:	PAUL EBMEIER
Credential	:
Telephone Number	:	417-627-8969

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	08/22/2020

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