Basic Information
| Provider Information | |||||||||
| NPI: | 1316269293 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON UNIVERSITY | ||||||||
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| OtherOrganizationName: | IMMUNOLOGY HEMASTASIS RESEARCH LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | CB 8118 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143625641 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 BARNES JEWISH HOSPITAL PLZ | ||||||||
| Address2: | SERVICE BLDG STE 262 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143625641 | ||||||||
| FaxNumber: | 3143620369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2010 | ||||||||
| LastUpdateDate: | 02/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | EBY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | LABORATORY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3143625641 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 26D1095501 | MO | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.