NPIMap

Organization Active NPI

St. John Physicians, Inc

Doing business as Jane Phillips Coffeyville Rural Health Clinic

  • Rural Health Clinic/Center
  • Coffeyville, KS
National Provider Identifier
1669792818
Registry record updated Aug 9, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
ST. JOHN PHYSICIANS, INC
Doing business as
Jane Phillips Coffeyville Rural Health Clinic
Practice address
1505 W 4TH St
Suite C
Coffeyville, KS 67337-3307
Phone
(620) 251-5400
Fax
(620) 251-5412
NPI assigned
Jun 9, 2010
Last updated
Aug 9, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 9, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Gayle J Burden
Title
Director
Phone
(918) 331-1090

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

1505 W 4TH St
Suite C
Coffeyville, KS 67337-3307

Mailing address

1505 W 11TH St
Suite C
Coffeyville, KS 67337-3613
Phone (620) 251-5400

Other names 1

  • Jane Phillips Coffeyville Rural Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20101123000257 KS Part B Supplier - Clinic/Group Practice 2567366495 Receives reassigned benefits from 16 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Caney, KS; Coffeyville, KS; Independence, KS
O20150429001424 KS Part A Provider - Rural Health Clinic 2567366495 1 other NPI on this enrollment
Practice locations: Coffeyville, KS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669792818. Details of each certification follow.

Rural health clinic certification: CCN 178934

Legal name
ST. JOHN PHYSICIANS, INC.
Doing business as
JANE PHILLIPS COFFEYVILLE RURAL HEALTH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 22, 1996
Last certification
Jul 6, 2011
Ownership / control type
1B
Most recent change of ownership
Jun 30, 2014 (3 total)
Organization structure
CorporationProprietary
Incorporated
Mar 2, 2005 in OK
Enrollment address
1505 W 11TH St
Ste C
Coffeyville, KS 67337-3614

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

1505 W 11th St
Ste C
Coffeyville, KS 67337
Phone (620) 251-5400

1505 W 4th St
Ste C
Coffeyville, KS 67337
Phone (620) 251-5400

1725 E 19th St
Ste 500
Tulsa, OK 74104
Phone (918) 403-7089

Ownership & related parties

All disclosed owners & managing parties 6

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Evelyn Carter Individual Corporate DirectorCoo Aug 1, 2024
W-2 Managing EmployeeCoo Aug 1, 2024
St. John Physicians, Inc. Organization, Tulsa, OK Corporation, For-profit, Chain home office Operational/Managerial Control Jun 30, 2014 100%
St John Health Systems Inc Organization, Tulsa, OK Corporation, Non-profit Operational/Managerial Control Jun 30, 2014
Roger Ray Individual W-2 Managing EmployeeSenior Director Jan 1, 2014
Utica Services Inc Organization, Tulsa, OK Corporation, For-profit Operational/Managerial Control Jun 30, 2014
Ascension Health Organization, Tulsa, OK Corporation, Non-profit Operational/Managerial Control Jun 30, 2014

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
SJC Caney Rural Health ClinicCaney, KS, CCN 173893 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jun 30, 2014
St John ClinicBarnsdall, OK, CCN 373824 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jun 1, 2015

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 164

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 164

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1276041600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1470700800000",
    "number": "1669792818",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1505 W 11TH ST",
            "address_2": "SUITE C",
            "city": "COFFEYVILLE",
            "state": "KS",
            "postal_code": "673373613",
            "telephone_number": "620-251-5400",
            "fax_number": "620-251-5412"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1505 W 4TH ST",
            "address_2": "SUITE C",
            "city": "COFFEYVILLE",
            "state": "KS",
            "postal_code": "673373307",
            "telephone_number": "620-251-5400",
            "fax_number": "620-251-5412"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. JOHN PHYSICIANS, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-06-09",
        "last_updated": "2016-08-09",
        "status": "A",
        "authorized_official_last_name": "BURDEN",
        "authorized_official_first_name": "GAYLE",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "918-331-1090"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jane Phillips Coffeyville Rural Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Coffeyville, KS

Sources for this page

Verify at the official NPI Registry.