Basic Information
| Provider Information | |||||||||
| NPI: | 1255522819 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RESPIRATORY DISEASE CONSULTANTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 LACKLAND HILL PKWY | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6 JUNGERMANN CIR | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633761621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364479277 | ||||||||
| FaxNumber: | 6364474276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | AHMAREEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD/MANAGING EMPLOYEE | ||||||||
| AuthorizedOfficialTelephone: | 6364479277 | ||||||||
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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 | 207RP1001X | 108033 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | DB4693 | 01 | MO | RR MEDICARE GROUP# | OTHER | 500573506 | 05 | MO | MEDICAID |