Basic Information
Provider Information | |||||||||
NPI: | 1790953909 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MISSOURI BAPTIST HOSPITAL OF SULLIVAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST. CLAIR CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 670 MASON RIDGE CENTER DR | ||||||||
Address2: | STE. 300 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631418573 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149967644 | ||||||||
FaxNumber: | 3149967658 | ||||||||
Practice Location | |||||||||
Address1: | 875 N COMMERCIAL AVE | ||||||||
Address2: |   | ||||||||
City: | SAINT CLAIR | ||||||||
State: | MO | ||||||||
PostalCode: | 630771118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6366297467 | ||||||||
FaxNumber: | 6366297464 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2008 | ||||||||
LastUpdateDate: | 02/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIDSON | ||||||||
AuthorizedOfficialFirstName: | RAYMOND | ||||||||
AuthorizedOfficialMiddleName: | P. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3142862025 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | II | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.