Basic Information
| Provider Information | |||||||||
| NPI: | 1992378384 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLUMINATION HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366857804 | ||||||||
| FaxNumber: | 3145762344 | ||||||||
| Practice Location | |||||||||
| Address1: | 2355 DOUGHERTY FERRY RD STE 410 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631223325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148354873 | ||||||||
| FaxNumber: | 3143366475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2021 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | SNIDER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | V.P. PHYSICIAN NETWORK | ||||||||
| AuthorizedOfficialTelephone: | 6366857804 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. LUKES MEDICAL GROUP | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083B0002X | N | 193200000X MULTI-SPECIALTY GROUP | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.