Basic Information
| Provider Information | |||||||||
| NPI: | 1801934609 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. CHARLES COUNTY CARDIOLOGY, 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 1ST CAPITOL DR | ||||||||
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| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369475000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TABER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6369475000 | ||||||||
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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 | 207RC0000X | R9F84 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.