MEDICARE: ST. JOHN BROKEN ARROW, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282N00000X	General Acute Care Hospital
2	282N00000X	General Acute Care Hospital	2380	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	370235	OTHER		MEDICARE CCN

General Provider Information

NPI Number	:	1497988596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JOHN BROKEN ARROW, INC

Provider Business Mailing Address
First Line	:	1000 W BOISE CIR
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4900
Country	:	US
Telephone Number	:	918-994-8100
Fax Number	:	918-994-8199

Provider Business Practice Location Address
First Line	:	1000 W BOISE CIR
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4900
Country	:	US
Telephone Number	:	918-994-8100
Fax Number	:	918-994-8199

Authorized Official
Title or Position	:	CEO
Name	:	MATT ADAMS
Credential	:
Telephone Number	:	918-994-8100

Provider Enumeration Date	:	08/24/2009
Last Update Date	:	10/02/2024

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