Basic Information
| Provider Information | |||||||||
| NPI: | 1013957562 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WASHINGTON UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7425 FORSYTH BLVD | ||||||||
| Address2: | CAMPUS BOX 8221 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631052171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149350770 | ||||||||
| FaxNumber: | 3149350575 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 FOREST PARK AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143623937 | ||||||||
| FaxNumber: | 3143623725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | EGHIGIAN | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3142730770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 08-01999 | 01 | MO | UHC GROUP NUMBER | OTHER | 552919508 | 05 | MO | MEDICAID | 0062375 | 01 | MO | SPECIAL HEALTH CARE NEEDS | OTHER | 610916400 | 01 | MO | DEPARTMENT OF LABOR | OTHER | 92215217 | 01 | IL | BLUE SHIELD GROUP | OTHER | 108RP6 | 01 | MO | BLUE SHIELD BILLING CODE | OTHER | 3697 | 01 | MO | GHP MASTER VENDOR | OTHER | 673341 | 01 | MO | AETNA HMO GROUP | OTHER |