Basic Information
| Provider Information | |||||||||
| NPI: | 1902867997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | K M B S C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 790129 | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631790129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174642966 | ||||||||
| FaxNumber: | 2174643193 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625213883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174642966 | ||||||||
| FaxNumber: | 2174643193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 01/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | STRAYER | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2174642966 | ||||||||
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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 | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0581522929 | 01 | IL | BCBS | OTHER |