1578537015 NPI number — MIDWEST CARDIOVASCULAR CENTER, LLC

Table of content: (NPI 1578537015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578537015 NPI number — MIDWEST CARDIOVASCULAR CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST CARDIOVASCULAR CENTER, 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:
1578537015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11475 OLDE CABIN RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-7128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-997-4622
Provider Business Mailing Address Fax Number:
314-997-3248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10012 KENNERLY RD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-2197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-842-9070
Provider Business Practice Location Address Fax Number:
314-842-9952
Provider Enumeration Date:
02/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EREKSON
Authorized Official First Name:
ROCK
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY/TREASURER
Authorized Official Telephone Number:
314-997-4622

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103800 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 123517 . This is a "BC/BS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 3400001 . This is a "UHC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 7326100 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 3749601-001 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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