Basic Information
| Provider Information | |||||||||
| NPI: | 1346749090 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GCXP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 797002 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631797000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885776337 | ||||||||
| FaxNumber: | 6186243387 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SAINT ELIZABETH BLVD | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622691099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342120 | ||||||||
| FaxNumber: | 9042658181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2018 | ||||||||
| LastUpdateDate: | 02/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | GLOVER | ||||||||
| AuthorizedOfficialFirstName: | CARMON | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8885776337 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.