1477694743 NPI number — RETINA GROUP LIMITED PC

Table of content: (NPI 1477694743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477694743 NPI number — RETINA GROUP LIMITED PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA GROUP LIMITED 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:
1477694743
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 503856
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:
63150-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-632-8100
Provider Business Mailing Address Fax Number:
618-632-8101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4550 MEMORIAL DR STE 350
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62226-5372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-632-8100
Provider Business Practice Location Address Fax Number:
618-632-8101
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANN
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-632-8100

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  036-094928 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 105431 , 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: 5234019 . This is a "AETNA MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 06030124 . This is a "BCBSIL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 143209 . This is a "BCBSMO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 3411178005 . This is a "CIGNA IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 3411178005 . This is a "CIGNA MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 000000012366 . This is a "ESSENCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 10585 . This is a "GHP IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CB6939 . This is a "RRMCRMO GROUP ID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 008257 . This is a "EXCLUSIVE CHOICE MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 000000012366 . This is a "ESSENCE MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 213418 . This is a "PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CB6940 . This is a "RRMCRIL GROUP ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 000015461 . This is a "PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 10585 . This is a "GHP MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 255484 . This is a "HEALTHLINK MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 255484 . This is a "HLTHLNK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 008257 . This is a "EXCLU CHOICE IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 5234019 . This is a "AETNA IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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