Healthcare Provider Details

I. General information

NPI: 1376579565
Provider Name (Legal Business Name): ST. JOHN'S MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N HOSPITAL DR SUITE 5
GIRARD KS
66743-2014
US

IV. Provider business mailing address

2631 CUNNINGHAM AVE SUITE A
JOPLIN MO
64804-1543
US

V. Phone/Fax

Practice location:
  • Phone: 620-724-4659
  • Fax: 620-724-6955
Mailing address:
  • Phone: 417-627-8967
  • Fax: 417-627-8951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PAUL EBMEIER
Title or Position: COO
Credential:
Phone: 417-627-8969