Basic Information
| Provider Information | |||||||||
| NPI: | 1235235532 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | NEUROMUSCULAR LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7425 FORSYTH BLVD | ||||||||
| Address2: | |||||||||
| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149350770 | ||||||||
| FaxNumber: | 3149350575 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 S EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143623281 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 09/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | EGHIGIAN | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3149350770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 26D0652044 | MO | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 702840109 | 05 | MO | MEDICAID |