Basic Information
| Provider Information | |||||||||
| NPI: | 1134227473 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VAN AMBURG & BUSIEK MDS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 S WOODS MILL RD | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366857804 | ||||||||
| FaxNumber: | 3145762344 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 S WOODS MILL RD STE 330E | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142056737 | ||||||||
| FaxNumber: | 3145762378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | SNIDER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP PHYSICIAN NETWORK | ||||||||
| AuthorizedOfficialTelephone: | 6366857804 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. LUKE'S MEDICAL GROUP | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 207RX0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 57201 | 01 | MO | GHP GROUP NUMBER | OTHER | 507202505 | 05 | MO | MEDICAID | DD9058 | 01 | MO | RR MEDICARE GROUP NUMBER | OTHER |