1871762385 NPI number — DOCTOR'S CLINICAL GROUP

Table of content: (NPI 1871762385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871762385 NPI number — DOCTOR'S CLINICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOCTOR'S CLINICAL GROUP
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:
1871762385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 790379
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:
63179-0379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-291-0505
Provider Business Mailing Address Fax Number:
314-291-0747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12255 DEPAUL DRIVE SUITE 865
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-291-0505
Provider Business Practice Location Address Fax Number:
314-291-0747
Provider Enumeration Date:
02/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
POETZ
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-291-0505

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  29351 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 152467 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0004255603 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 240407908 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 250759 . This is a "HARMONY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 3065209001 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 489409703 . This is a "MERCYCARE PLUS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: D92011 . This is a "HUMANA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 080130617 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 103753 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 123036 . This is a "GHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 489409703 . This is a "COMMUNITY CARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 01-00207 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 100805 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 100805 . This is a "BC/BS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 2064 . This is a "HEALTHCARE USA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 77072 . This is a "WELLCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: D92011 . This is a "EXCLUSIVE CHOICE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1013577 . This is a "CARE PARTNERS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1940001 . This is a "PARTNERS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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