Basic Information
Provider Information | |||||||||
NPI: | 1487694337 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WASHINGTON UNIVERSITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WASHINGTON UNIVERSITY, DEPARTMENT OF PLASTIC SURGERY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 06/08/2006 | ||||||||
LastUpdateDate: | 03/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EGHIGIAN | ||||||||
AuthorizedOfficialFirstName: | CATHY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 3142730770 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 0201537 | 01 | MO | SPECIAL HEALTH CARE NEEDS | OTHER | 13-09005 | 01 | MO | UHC GROUP NUMBER | OTHER | 673341 | 01 | MO | AETNA HMO GROUP | OTHER | 0255860002 | 01 | MO | DME MEDICARE GROUP | OTHER | 610916400 | 01 | MO | DEPARTMENT OF LABOR | OTHER | 92215227 | 01 | IL | BLUE SHIELD | OTHER | 3857 | 01 | MO | GHP MASTER VENDOR | OTHER | 553061300 | 01 | MO | MEDICAID PHARMACY NUMBER | OTHER | 553061300 | 05 | MO |   | MEDICAID |