Provider Demographics
NPI:1669792818
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:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-331-1090
Mailing Address - Street 1:1505 W 11TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-3613
Mailing Address - Country:US
Mailing Address - Phone:620-251-5400
Mailing Address - Fax:620-251-5412
Practice Address - Street 1:1505 W 4TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3307
Practice Address - Country:US
Practice Address - Phone:620-251-5400
Practice Address - Fax:620-251-5412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS178934Medicare Oscar/Certification