Basic Information
| Provider Information | |||||||||
| NPI: | 1194778415 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LOUIS PATHOLOGY ASSOC INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20452 | ||||||||
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| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432200452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144578180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 S NEW BALLAS RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142511884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | POESCHL | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | DRAKE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3142511884 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 501888903 | 05 | MO | MEDICAID | 000010864 | 01 | MO | MEDICARE PTAN | OTHER |