Basic Information
Provider Information | |||||||||
NPI: | 1487890406 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHESTERFIELD REHABILITATION PHYSICIANS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 232 S WOODS MILL RD | ||||||||
Address2: |   | ||||||||
City: | CHESTERFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 630173417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6366857804 | ||||||||
FaxNumber: | 3145762344 | ||||||||
Practice Location | |||||||||
Address1: | 224 S WOODS MILL RD STE 570 | ||||||||
Address2: |   | ||||||||
City: | CHESTERFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 630173513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3142056898 | ||||||||
FaxNumber: | 3145905911 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2008 | ||||||||
LastUpdateDate: | 12/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SNIDER | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP PHYSICIAN NETWORK | ||||||||
AuthorizedOfficialTelephone: | 6366857804 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ST. LUKE'S MEDICAL GROUP | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
No ID Information.