Healthcare Provider Details

I. General information

NPI: 1154416188
Provider Name (Legal Business Name): ST. JOHN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 S UTICA AVE
TULSA OK
74104
US

IV. Provider business mailing address

1923 S UTICA AVE
TULSA OK
74104
US

V. Phone/Fax

Practice location:
  • Phone: 918-744-2345
  • Fax:
Mailing address:
  • Phone: 918-744-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2265
License Number StateOK

VIII. Authorized Official

Name: SR. M. THERESE GOTTSCHALK
Title or Position: PRESIDENT/CHIEF EXECUTIVE OFFICER
Credential:
Phone: 918-744-2180