Basic Information
| Provider Information | |||||||||
| NPI: | 1093092611 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LOUIS BARIATRICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270419 | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143664874 | ||||||||
| FaxNumber: | 3143664875 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 HWY 61 S | ||||||||
| Address2: | SUITE G50 | ||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143664874 | ||||||||
| FaxNumber: | 3143664875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2011 | ||||||||
| LastUpdateDate: | 01/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | SNOW | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3143664874 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2011030112 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.