Healthcare Provider Details

I. General information

NPI: 1215695945
Provider Name (Legal Business Name): PRIMARY CARE OF ST. LUKE'S, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S WOODS MILL RD STE 630N
CHESTERFIELD MO
63017-3645
US

IV. Provider business mailing address

121 SAINT LUKES CENTER DR STE 200
CHESTERFIELD MO
63017-3518
US

V. Phone/Fax

Practice location:
  • Phone: 636-685-7727
  • Fax: 314-590-5919
Mailing address:
  • Phone: 314-576-2475
  • Fax: 314-576-2410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JAMES SNIDER
Title or Position: V.P. PHYSICIAN NETWORK
Credential:
Phone: 636-685-7804