Basic Information
| Provider Information | |||||||||
| NPI: | 1144291659 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | E. SUTPHEN MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10010 KENNERLY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145251688 | ||||||||
| FaxNumber: | 3145251689 | ||||||||
| Practice Location | |||||||||
| Address1: | 10010 KENNERLY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145251688 | ||||||||
| FaxNumber: | 3145251689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 06/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | SUTPHEN | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3145251688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | R2P24 | MO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 507584704 | 05 | MO | MEDICAID | DC0795 | 01 | MO | RAILROAD MEDICARE | OTHER |