Basic Information
| Provider Information | |||||||||
| NPI: | 1427098938 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WASHINGTON UNIVERSITY, DEPARTMENT OF PEDIATRIC SURGERY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4240 DUNCAN AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142730770 | ||||||||
| FaxNumber: | 3142730575 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143624964 | ||||||||
| FaxNumber: | 3147474871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | EGHIGIAN | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3142730770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 17-09037 | 01 | MO | UHC GROUP NUMBER | OTHER | 610916400 | 01 | MO | DEPARTMENT OF LABOR | OTHER | 673341 | 01 | MO | AETNA HMO GROUP | OTHER | 92215227 | 01 | IL | BLUE SHIELD | OTHER | 377 | 01 | MO | GHP MASTER VENDOR | OTHER | 6112358 | 01 | MO | SPECIAL HEALTH CARE NEEDS | OTHER | 553061201 | 05 | MO | MEDICAID |