Basic Information
Provider Information | |||||||||
NPI: | 1457361024 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHRISTIAN HOSPITAL NORTHEAST- NORTHWEST | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1225 GRAHAM RD | ||||||||
Address2: |   | ||||||||
City: | FLORISSANT | ||||||||
State: | MO | ||||||||
PostalCode: | 630318012 | ||||||||
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: | 11/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOESTERER | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
AuthorizedOfficialTelephone: | 3146535715 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CHRISTIAN HOSPITAL NORTHEAST-NORTHWEST | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 4356057893 | 01 |   | AETNA | OTHER | 39 | 01 |   | BLUE CROSS OF IL | OTHER | 5020071 | 01 |   | UNITED HEALTHCARE | OTHER | 769 | 01 |   | ADVANTRA | OTHER | 103187 | 01 |   | HEALTHLINK | OTHER | 10490704 | 05 | MO |   | MEDICAID | 39 | 01 |   | BLUE CROSS OF MO | OTHER | 260159 | 01 |   | MERCY HEALTHPLAN | OTHER |