Basic Information
| Provider Information | |||||||||
| NPI: | 1780657023 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LOUIS UNIVERSITY | ||||||||
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| OtherOrganizationName: | SLUCARE DEPARTMENT OF PATHOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3545 LINDELL BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631031020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149776828 | ||||||||
| FaxNumber: | 3149776872 | ||||||||
| Practice Location | |||||||||
| Address1: | 1402 SOUTH GRAND | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145778475 | ||||||||
| FaxNumber: | 3142685478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | LANXON | ||||||||
| AuthorizedOfficialFirstName: | ALYCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3149776828 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 207ZB0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZC0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 554850230 | 05 | MO | MEDICAID |