Basic Information
Provider Information | |||||||||
NPI: | 1699927020 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKUPS | ||||||||
FirstName: | RONALD | ||||||||
MiddleName: | RICHARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 660 S EUCLID AVE | ||||||||
Address2: | CB 8118 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631101010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143625641 | ||||||||
FaxNumber: | 3143620369 | ||||||||
Practice Location | |||||||||
Address1: | 1 BARNES JEWISH HOSPITAL PLZ | ||||||||
Address2: | DEPT PATHOLOGY | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631101003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143625641 | ||||||||
FaxNumber: | 3143620369 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2008 | ||||||||
LastUpdateDate: | 11/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZB0001X | 2012005897 | MO | N |   | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZP0105X | 2012005897 | MO | Y |   | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
ID | Type | State | Issuer | Description | 209529908 | 05 | MO |   | MEDICAID |