Basic Information
| Provider Information | |||||||||
| NPI: | 1366452930 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTIAN HOSPITAL NORTHEAST- NORTHWEST | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 GRAHAM RD | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630318014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146535000 | ||||||||
| FaxNumber: | 3146534153 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 GRAHAM RD | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630318014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146535000 | ||||||||
| FaxNumber: | 3146534153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KATSIANIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3146535062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHRISTIAN HOSPITAL NORTHEAST-NORTHWEST | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 425-9 | MO | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 39 | 01 | BLUE CROSS OF MO | OTHER | 10490704 | 05 | MO | MEDICAID | 39 | 01 | BLUE CROSS OF IL | OTHER | 4356057893 | 01 | AETNA | OTHER |