1811056005 NPI number — ALBANNA NEUROSURGICAL CONSULTANTS A PROFESSIONAL CORP

Table of content: (NPI 1811056005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811056005 NPI number — ALBANNA NEUROSURGICAL CONSULTANTS A PROFESSIONAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALBANNA NEUROSURGICAL CONSULTANTS A PROFESSIONAL CORP
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:
1811056005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 CEDAR PLAZA PKWY
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-849-9090
Provider Business Mailing Address Fax Number:
314-849-4165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 CEDAR PLAZA PKWY
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-849-9090
Provider Business Practice Location Address Fax Number:
314-849-4165
Provider Enumeration Date:
12/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KETCHERSIDE
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADM CORP SEC
Authorized Official Telephone Number:
314-849-9090

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 508602802 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3692 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 096K1 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".