Basic Information
| Provider Information | |||||||||
| NPI: | 1407218365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST ANTHONYS PHYSICIAN ORGANIZATION OF ILLINOIS | ||||||||
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| OtherOrganizationName: | ST ANTHONY'S NEUROSURGERY SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9735 LANDMARK PARKWAY DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631271646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435999 | ||||||||
| FaxNumber: | 3145436836 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 S BURNS AVE | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622861895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435999 | ||||||||
| FaxNumber: | 3145435994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 03/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | MORTON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 3145251053 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.