1366692915 NPI number — DES PERES HOSPITAL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366692915 NPI number — DES PERES HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DES PERES HOSPITAL
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:
6
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:
1366692915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1103 W LIBERTY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63640-1921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-756-6751
Provider Business Mailing Address Fax Number:
573-756-6807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2345 DOUGHERTY FERRY RD
Provider Second Line Business Practice Location Address:
ATTENTION MEDICAL EDUCATION
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63122-3313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-966-9491
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
JAMESY
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
573-760-8605

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2009018166 . This is a "MISSOURI BOARD OF HEALING ARTS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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