Healthcare Provider Details

I. General information

NPI: 1801831045
Provider Name (Legal Business Name): ST LOUIS CARDIOLOGY CONSULTANTS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEMORIAL DR STE 106
ALTON IL
62002-6723
US

IV. Provider business mailing address

2 MEMORIAL DR STE 106
ALTON IL
62002-6723
US

V. Phone/Fax

Practice location:
  • Phone: 618-433-1861
  • Fax: 618-433-9274
Mailing address:
  • Phone: 618-433-1861
  • Fax: 618-433-9274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMER THANAVARO
Title or Position: MD
Credential: MD
Phone: 618-433-1861