Basic Information
| Provider Information | |||||||||
| NPI: | 1215148952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | SATHEAVY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11475 OLDE CABIN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631417128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149918200 | ||||||||
| FaxNumber: | 3145691787 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 PATIENTS FIRST DR | ||||||||
| Address2: | DEPT OF RADIOLOGY | ||||||||
| City: | WASHINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630904700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363901575 | ||||||||
| FaxNumber: | 6363909710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 05/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2010007591 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036128244 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD201166 | LA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | E8090 | AR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1215148952 | 05 | MO | MEDICAID |