Basic Information
Provider Information | |||||||||
NPI: | 1164553590 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICIAN GROUPS LC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CARSON AGEE MD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 670 MASON RIDGE CENTER DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631418573 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149967644 | ||||||||
FaxNumber: | 3149967658 | ||||||||
Practice Location | |||||||||
Address1: | 2 PROGRESS POINT PARKWAY | ||||||||
Address2: | SUITE 101C | ||||||||
City: | O'FALLON | ||||||||
State: | MO | ||||||||
PostalCode: | 63368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6363443102 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2007 | ||||||||
LastUpdateDate: | 04/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIDSON | ||||||||
AuthorizedOfficialFirstName: | RAYMOND | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3142862028 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | II | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.