Provider Demographics
NPI:1861794448
Name:ST JOHN SAPULPA
Entity type:Organization
Organization Name:ST JOHN SAPULPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MHA
Authorized Official - Phone:918-224-4280
Mailing Address - Street 1:PO BOX 1368
Mailing Address - Street 2:1004 N BRYAN
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74067-1368
Mailing Address - Country:US
Mailing Address - Phone:918-224-4280
Mailing Address - Fax:918-227-3927
Practice Address - Street 1:1004 E BRYAN AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4513
Practice Address - Country:US
Practice Address - Phone:918-224-4280
Practice Address - Fax:918-227-3927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2310282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK00037003301OtherMEDICARE
OK100699550DMedicaid
OK371312Medicare Oscar/Certification