1134352396 NPI number — SOUTH COUNTY INTERNAL MEDICINE PHYSICIANS, LLC

Table of content: (NPI 1134352396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134352396 NPI number — SOUTH COUNTY INTERNAL MEDICINE PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH COUNTY INTERNAL MEDICINE PHYSICIANS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134352396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12342 SPANISH TRACE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYLAND HEIGHTS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63043-2306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-542-3686
Provider Business Mailing Address Fax Number:
888-756-6714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1479 HIGHWAY 61
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FESTUS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63028-4109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-579-6148
Provider Business Practice Location Address Fax Number:
888-756-6714
Provider Enumeration Date:
09/03/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NALLAMOTHU
Authorized Official First Name:
RATAN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
636-579-6148

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  2009008003 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)