1861503120 NPI number — MEDICAL ONCOLOGY/HEMATOLOGY CONSULTANTS PC

Table of content: (NPI 1861503120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861503120 NPI number — MEDICAL ONCOLOGY/HEMATOLOGY CONSULTANTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL ONCOLOGY/HEMATOLOGY CONSULTANTS PC
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:
1861503120
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 958858
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63195-8858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-878-0163
Provider Business Mailing Address Fax Number:
314-842-5921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12700 SOUTHFORK RD
Provider Second Line Business Practice Location Address:
STE.125
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-842-6472
Provider Business Practice Location Address Fax Number:
314-842-5921
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORICONI
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-842-6472

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  R1B83 , 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)

  • Identifier: 201373925 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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