Healthcare Provider Details

I. General information

NPI: 1255388849
Provider Name (Legal Business Name): ST JOHNS EXPRESS CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 S RANGELINE RD
JOPLIN MO
64801-5588
US

IV. Provider business mailing address

PO BOX 1240
JOPLIN MO
64802-1240
US

V. Phone/Fax

Practice location:
  • Phone: 417-625-2878
  • Fax: 417-625-2807
Mailing address:
  • Phone: 417-625-2878
  • Fax: 417-625-2807

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

VIII. Authorized Official

Name: PAUL EBMEIER
Title or Position: CEO
Credential:
Phone: 417-625-2878