Basic Information
| Provider Information | |||||||||
| NPI: | 1992746903 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WASHINGTON UNIVERSITY, DEPT OF INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4240 DUNCAN AVE | ||||||||
| Address2: | CAMPUS BOX 8221 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142730770 | ||||||||
| FaxNumber: | 3142730470 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147475192 | ||||||||
| FaxNumber: | 3142861021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 07/25/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | EGHIGIAN | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING INFORMATION | ||||||||
| AuthorizedOfficialTelephone: | 3142730770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 603025305 | 05 | MO | MEDICAID | 673341 | 01 | MO | AETNAHMOGROUP | OTHER | 3688 | 01 | MO | GHPMASTERVENDORNUMBER | OTHER | 92215194 | 01 | IL | BLUECROSS/BLUESHIELD-IL | OTHER | 552927808 | 05 | MO | MEDICAID |