Basic Information
| Provider Information | |||||||||
| NPI: | 1649426768 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM ST. JOSEPH HEALTH CENTER | ||||||||
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| OtherOrganizationName: | THE IMAGING CENTER AT ST. JOSEPH MEDICAL PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 LACKLAND HILL PKWY | ||||||||
| Address2: | ATTN CREDENTIALING DEPARTMENT | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
| FaxNumber: | 6364987420 | ||||||||
| Practice Location | |||||||||
| Address1: | 1475 KISKER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633048781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364987400 | ||||||||
| FaxNumber: | 6364987420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2008 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | HAILSTONE | ||||||||
| AuthorizedOfficialFirstName: | SHERLYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6369475076 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.