Basic Information
| Provider Information | |||||||||
| NPI: | 1134672587 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHESTERFIELD CARDIOLOGY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR | ||||||||
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| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366857804 | ||||||||
| FaxNumber: | 3145762344 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 S WOODS MILL RD STE 560 | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144858788 | ||||||||
| FaxNumber: | 3145905910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2016 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | SNIDER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP PHYSICIAN NETWORK | ||||||||
| AuthorizedOfficialTelephone: | 6366857804 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. LUKE'S MEDICAL GROUP | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1134672587 | 05 | MO | MEDICAID |