Healthcare Provider Details

I. General information

NPI: 1154354660
Provider Name (Legal Business Name): ST. JOHN'S EMERGENCY PHYSICIANS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 04/05/2020
Certification Date: 04/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2367
US

IV. Provider business mailing address

PO BOX 101519
PASADENA CA
91189-0009
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-2000
  • Fax:
Mailing address:
  • Phone: 626-447-0296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RODERICK W. BEAVER
Title or Position: PRESIDENT
Credential: MD
Phone: 360-448-0587