Provider Demographics
NPI:1912961418
Name:ST. JOHN PHYSICIANS, INC
Entity type:Organization
Organization Name:ST. JOHN PHYSICIANS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-331-1090
Mailing Address - Street 1:218 W 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:CANEY
Mailing Address - State:KS
Mailing Address - Zip Code:67333-1462
Mailing Address - Country:US
Mailing Address - Phone:620-879-2182
Mailing Address - Fax:620-879-2246
Practice Address - Street 1:218 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:CANEY
Practice Address - State:KS
Practice Address - Zip Code:67333-1462
Practice Address - Country:US
Practice Address - Phone:620-879-2182
Practice Address - Fax:620-879-2246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363L00000X
KS1501670261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS173893Medicare Oscar/Certification