Healthcare Provider Details

I. General information

NPI: 1811084635
Provider Name (Legal Business Name): ST JOHNS REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2931 MCCLELLAND BLVD
JOPLIN MO
64804-1633
US

IV. Provider business mailing address

2727 MCCLELLAND BLVD
JOPLIN MO
64804-1695
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-2727
  • Fax: 417-625-2910
Mailing address:
  • Phone: 417-781-2727
  • Fax: 417-625-2910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number11840
License Number StateMO

VIII. Authorized Official

Name: MR. GARY PULSIPHER
Title or Position: CEO PRESIDENT
Credential:
Phone: 417-781-2727