Healthcare Provider Details

I. General information

NPI: 1700032653
Provider Name (Legal Business Name): ST JOHN'S REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 MCCLELLAND BLVD
JOPLIN MO
64804-1626
US

IV. Provider business mailing address

PO BOX 760
JOPLIN MO
64802-0760
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-2727
  • Fax:
Mailing address:
  • Phone: 417-624-3040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JOHN MENTGEN
Title or Position: COO
Credential:
Phone: 417-659-6700