1245652759 NPI number — ST. ANTHONY'S PHYSICIAN ORGANIZATION

Table of content: (NPI 1245652759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245652759 NPI number — ST. ANTHONY'S PHYSICIAN ORGANIZATION

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
ST. ANTHONY'S PHYSICIAN ORGANIZATION
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:
MERCY CLINIC SOUTH PHYSICIANS
Provider Other Organization Name Type Code:
3
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:
1245652759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10012 KENNERLY RD STE 404
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:
63128-2197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-543-5911
Provider Business Mailing Address Fax Number:
314-543-5911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10012 KENNERLY RD
Provider Second Line Business Practice Location Address:
SUITE 104
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:
314-543-5911
Provider Business Practice Location Address Fax Number:
314-543-5914
Provider Enumeration Date:
01/17/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MATEJKA
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO EAST COMMUNITIES & SFO
Authorized Official Telephone Number:
314-251-1958

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000015644 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".