1366543746 NPI number — DR. ANDREW T PICKENS III MD

Table of content: DR. ANDREW T PICKENS III MD (NPI 1366543746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366543746 NPI number — DR. ANDREW T PICKENS III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICKENS
Provider First Name:
ANDREW
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1366543746
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1034 S BRENTWOOD BLVD
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-727-2700
Provider Business Mailing Address Fax Number:
314-727-2773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1034 S BRENTWOOD BLVD
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-727-2700
Provider Business Practice Location Address Fax Number:
314-727-2773
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  32150 , 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: A10290 . This is a "MERCY HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57158 . This is a "CMR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 015011 . This is a "EXCLUSIVE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10742 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 102091 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 154119 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 154119 . This is a "UNITED BEHAVIORAL HEALTH" identifier . This identifiers is of the category "OTHER".




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