Basic Information
| Provider Information | |||||||||
| NPI: | 1417335167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSOURI HEART AND VASCULAR INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1028 S KIRKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | KIRKWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631227222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143942950 | ||||||||
| FaxNumber: | 3143942253 | ||||||||
| Practice Location | |||||||||
| Address1: | 1028 S KIRKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | KIRKWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631227222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143942950 | ||||||||
| FaxNumber: | 3143942253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2015 | ||||||||
| LastUpdateDate: | 06/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | HORACE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6189738740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.