Basic Information
| Provider Information | |||||||||
| NPI: | 1043386162 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIAN GROUPS LC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHWEST PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 670 MASON RIDGE CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149967644 | ||||||||
| FaxNumber: | 3149967658 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 GRAHAM RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630318014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148386700 | ||||||||
| FaxNumber: | 3148386020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 03/26/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIDSON | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3142862028 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | CN1994 | 01 | MEDICARE RAILROAD | OTHER |