Basic Information
| Provider Information | |||||||||
| NPI: | 1407216336 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST ANTHONYS PHYSICIAN ORGANIZATION HOSPITALIST SERVICES, L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MERCY CLINIC SOUTH HOSPITALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9735 LANDMARK PARKWAY DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631271646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145251328 | ||||||||
| FaxNumber: | 3145251378 | ||||||||
| Practice Location | |||||||||
| Address1: | 10010 KENNERLY RD | ||||||||
| Address2: | 3 SOUTHBRIDGE | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145251328 | ||||||||
| FaxNumber: | 3145251378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2016 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATEJKA | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO EAST COMMUNITIES & SFO | ||||||||
| AuthorizedOfficialTelephone: | 3142511958 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | MA3704 | 01 | MO | MEDICARE PTAN | OTHER |