Provider Demographics
NPI:1902993728
Name:ST JOHNS REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:ST JOHNS REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT 7 CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PULSIPHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-781-2727
Mailing Address - Street 1:2727 MCCLELLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1695
Mailing Address - Country:US
Mailing Address - Phone:417-781-2727
Mailing Address - Fax:417-625-2910
Practice Address - Street 1:2931 MCCLELLAND BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1633
Practice Address - Country:US
Practice Address - Phone:417-781-2727
Practice Address - Fax:417-625-2910
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC HEALTH INITIATIVES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-05
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11848314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100000880AOtherMEDICAID
OK100693700AOtherMEDICAID
MO010564508Medicaid
KS100000880AOtherMEDICAID
OK100693700AOtherMEDICAID