Provider Demographics
NPI:1962516096
Name:ST. JOHN'S REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:ST. JOHN'S REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARALIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-781-2727
Mailing Address - Street 1:4500 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4404
Mailing Address - Country:US
Mailing Address - Phone:417-781-2204
Mailing Address - Fax:417-781-2517
Practice Address - Street 1:4500 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4404
Practice Address - Country:US
Practice Address - Phone:417-781-2204
Practice Address - Fax:417-781-2517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO127-21251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100000880FMedicaid
MO580564508Medicaid
MO267049Medicare Oscar/Certification