Basic Information
Provider Information | |||||||||
NPI: | 1639162530 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KING | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11125 DUNN RD | ||||||||
Address2: | STE 204 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631366132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3148395522 | ||||||||
FaxNumber: | 3148395351 | ||||||||
Practice Location | |||||||||
Address1: | 11125 DUNN RD | ||||||||
Address2: | STE 204 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631366132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3148395522 | ||||||||
FaxNumber: | 3148395351 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2005 | ||||||||
LastUpdateDate: | 12/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | R7F82 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 6327V8816 | 01 |   | HCUSA | OTHER | E36005 | 01 |   | MERCY | OTHER | 3156370 | 01 |   | CIGNA | OTHER | 42693V30946 | 01 |   | HLTHPART | OTHER | 000000013834 | 01 |   | ESSENCE | OTHER | 060067901 | 01 | IL | ILRRMCR | OTHER | 060067902 | 01 | MO | MORRMCR | OTHER | 206707606 | 05 | MO |   | MEDICAID | 4334049 | 01 |   | AETNA | OTHER | O21267 | 01 |   | JFMOLLOY/FMH | OTHER | 20502 | 01 | MO | MOBS/BLCHOICE | OTHER | 431098908 | 01 |   | TRICARE | OTHER | 123148 | 01 |   | HLNK | OTHER | 2500128 | 01 |   | UNC | OTHER | 1955V3831 | 01 |   | GHP/CMR | OTHER |