Basic Information
| Provider Information | |||||||||
| NPI: | 1306804489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN AMBURG | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 S WOODS MILL RD | ||||||||
| Address2: | SUITE 330 EAST | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142056737 | ||||||||
| FaxNumber: | 3145762378 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 S WOODS MILL RD | ||||||||
| Address2: | SUITE 330 EAST | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142056737 | ||||||||
| FaxNumber: | 3145762378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | R5296 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 201245461 | 05 | MO | MEDICAID | 241963 | 01 | MO | GROUP HEALTH PLAN | OTHER | 0280272087 | 01 | MO | ILLINOIS PUBLIC AID | OTHER | 14488 | 01 | MO | BC/BS OF MISSOURI | OTHER | 4061290 | 01 | MO | AETNA | OTHER | 44637 | 01 | MO | CIGNA | OTHER | 182403 | 01 | MO | HEALTHLINK | OTHER |