Basic Information
| Provider Information | |||||||||
| NPI: | 1720726748 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VITAE HEALTH MEDICAL MISSOURI LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 W GOLF RD STE 26 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600053923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2247778034 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3625 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631104048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147712990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | AMISH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8338482347 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.