MEDICARE: ST. JOHN DIALYSIS, LLC

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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	2265	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000370114002	OTHER	OK	BCBS

General Provider Information

NPI Number	:	1902984156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JOHN DIALYSIS, LLC

Provider Business Mailing Address
First Line	:	1923 S UTICA AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74104-6520
Country	:	US
Telephone Number	:	918-744-2345
Fax Number	:

Provider Business Practice Location Address
First Line	:	1923 EAST 21ST STREET
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74114-1402
Country	:	US
Telephone Number	:	918-744-3535
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CHIEF EXECUTIVE OFFICER
Name	:	SR. M. THERESE GOTTSCHALK
Credential	:
Telephone Number	:	918-744-2180

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	02/12/2008

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