Healthcare Provider Details

I. General information

NPI: 1255388039
Provider Name (Legal Business Name): ST. JOHN'S MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 S ROUSE ST SUITE C
PITTSBURG KS
66762-6620
US

IV. Provider business mailing address

1701 W 26TH ST SUITE B
JOPLIN MO
64804-1513
US

V. Phone/Fax

Practice location:
  • Phone: 417-627-8967
  • Fax: 417-627-8951
Mailing address:
  • Phone: 417-627-8967
  • Fax: 417-627-8920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBIN SUMNER
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 417-627-8930