Basic Information
| Provider Information | |||||||||
| NPI: | 1801806112 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STAN L LONDON MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 LACKLAND HILL PKWY | ||||||||
| Address2: | ATTNT: CREDENTIALING DEPT | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
| FaxNumber: | 3148101399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 N MASON RD | ||||||||
| Address2: | STE G03 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148787899 | ||||||||
| FaxNumber: | 3142051020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | LONDON | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3145692294 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 24858 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.