1497944094 NPI number — PARKSIDE SURGERY AND MEDICINE

Table of content: (NPI 1497944094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497944094 NPI number — PARKSIDE SURGERY AND MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARKSIDE SURGERY AND MEDICINE
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:
1497944094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6125 CLAYTON AVE
Provider Second Line Business Mailing Address:
SUITE 430
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63139-3265
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-768-3634
Provider Business Mailing Address Fax Number:
314-768-3638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6125 CLAYTON AVE
Provider Second Line Business Practice Location Address:
SUITE 430
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63139-3265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-768-3634
Provider Business Practice Location Address Fax Number:
314-768-3638
Provider Enumeration Date:
10/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOSLEY
Authorized Official First Name:
JULIAN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
GENERAL SURGEON/OWNER
Authorized Official Telephone Number:
314-768-3634

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  R5845 , 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: 197390 . This is a "BCBS MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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