Basic Information
| Provider Information | |||||||||
| NPI: | 1013329150 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN AFFILIATES OF ST. LUKE'S MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145762490 | ||||||||
| FaxNumber: | 3145762344 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145762475 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2014 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | SONNE | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXEC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3145762490 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. LUKE'S MEDICAL GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.