Basic Information
| Provider Information | |||||||||
| NPI: | 1649465808 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT LUKE'S HOSPITAL MEDICAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 504552 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631500001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132341697 | ||||||||
| FaxNumber: | 9132341116 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 WORNALL RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641113220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169323503 | ||||||||
| FaxNumber: | 8169325990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 04/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | THORPE | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8169323503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | LC0830995 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 39122011 | 01 | BCBS OF KANSAS CITY MO | OTHER | DG5646 | 01 | RR MEDICARE | OTHER |