Basic Information
| Provider Information | |||||||||
| NPI: | 1497928907 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST ANTHONY'S PHYSICIAN ORGANIZATION PRIVATE PRACTICES LC | ||||||||
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| OtherOrganizationName: | ST ANTHONY'S BEHAVIORAL HEALTH GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10004 KENNERLY RD | ||||||||
| Address2: | STE 364-B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145254429 | ||||||||
| FaxNumber: | 3145256270 | ||||||||
| Practice Location | |||||||||
| Address1: | 10004 KENNERLY RD | ||||||||
| Address2: | STE 364-B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145254429 | ||||||||
| FaxNumber: | 3145256270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 06/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | HINKLE | ||||||||
| AuthorizedOfficialFirstName: | DAVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3145435988 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.