Basic Information
| Provider Information | |||||||||
| NPI: | 1023017746 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SA HOSPITAL ACQUISITION GROUP, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SOUTH CITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3933 SOUTH BROADWAY STREET | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631184601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148657902 | ||||||||
| FaxNumber: | 3148657938 | ||||||||
| Practice Location | |||||||||
| Address1: | 3933 SOUTH BROADWAY STREET | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631184601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148657902 | ||||||||
| FaxNumber: | 3148657938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HECHT | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3148657142 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 512-1 | MO | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 010635001 | 05 | MO | MEDICAID |