Basic Information
| Provider Information | |||||||||
| NPI: | 1861611493 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT LOUIS UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SLUCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3691 RUTGER ST | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149776828 | ||||||||
| FaxNumber: | 3149776777 | ||||||||
| Practice Location | |||||||||
| Address1: | 3660 VISTA AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149776125 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SEAY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3149776828 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
No ID Information.