Basic Information
| Provider Information | |||||||||
| NPI: | 1225425630 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. ANTHONY'S PHYSICIAN ORGANIZATION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY CLINIC SOUTH PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9735 LANDMARK PARKWAY DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631271646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145436985 | ||||||||
| FaxNumber: | 3145436836 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 THRESHER DR | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630251923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435968 | ||||||||
| FaxNumber: | 3145435918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2015 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | MATEJKA | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO EAST COMMUNITIES & SFO | ||||||||
| AuthorizedOfficialTelephone: | 3142511958 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000015644 | 01 | MO | MEDICARE GROUP PTAN # | OTHER |