Basic Information
| Provider Information | |||||||||
| NPI: | 1518062017 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHN'S CARDIOVASCULAR ASSOCIATES L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PREMIER HEART GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144853500 | ||||||||
| FaxNumber: | 3144853520 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144853500 | ||||||||
| FaxNumber: | 3144853520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 02/01/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEZEI | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3144853500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | MO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.