Basic Information
| Provider Information | |||||||||
| NPI: | 1356304489 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. FRANCIS MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. FRANCIS MEDICAL CENTER ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 SAINT FRANCIS DR | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637035049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733313000 | ||||||||
| FaxNumber: | 5733313015 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 SAINT FRANCIS DR | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733313000 | ||||||||
| FaxNumber: | 9133415797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | WILKERSON | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5733315583 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01440833 | 05 | KY | MEDICAID | 101DT5001 | 01 | MO | ANTHEM HEALTH NET | OTHER | 166636 | 01 | MO | BCBS | OTHER | 540160835 | 05 | MO | MEDICAID | 110375 | 01 | MO | HEALTHLINK | OTHER | C43475 | 01 | MO | RAILROAD MEDICARE | OTHER |