Basic Information
| Provider Information | |||||||||
| NPI: | 1114038494 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT FRANCIS MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THORACIC AND CARDIOVASCULAR SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 SAINT FRANCIS DR | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637035049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733315228 | ||||||||
| FaxNumber: | 5733315039 | ||||||||
| Practice Location | |||||||||
| Address1: | 3250 GORDONVILLE RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733313155 | ||||||||
| FaxNumber: | 5733315096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | WILKERSON | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5733315583 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.