Basic Information
| Provider Information | |||||||||
| NPI: | 1639236136 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LOUIS GASTROENTEROLOGY CONSULTANTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10012 KENNERLY RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435200 | ||||||||
| FaxNumber: | 3145435219 | ||||||||
| Practice Location | |||||||||
| Address1: | 10012 KENNERLY RD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435200 | ||||||||
| FaxNumber: | 3145435219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 11/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | BRADY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3145435200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 502449705 | 05 | MO | MEDICAID |