Organization
ST JOHNS CLINIC INC
Active
Other names
SJC-BERRYVILLE FAMILY PRACTICE
Organization subpart
No
Provider details
NPI number
Authorized official
VICKIE JENKINS (PROVIDER ENROLLMENT COORDINATOR)
(417) 829-4264
Entity
Organization
Contact information
Practice address
613 ORCHARD DR, BERRYVILLE, AR 72616-5013
(870) 423-7171
(870) 423-1032
Mailing address
PO BOX 2580, SPRINGFIELD, MO 65801-2580
(417) 829-4620
(417) 829-4316
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
C4889
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
150959002
—
AR
01
—
CR0464
TRAVELERS/RR MEDICARE #
AR
Enumeration date
11/16/2006
Last updated
06/27/2008
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