Healthcare Provider Details

I. General information

NPI: 1679836381
Provider Name (Legal Business Name): JEFFERSON CARDIOVASCULAR AND THORACIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 US HIGHWAY 61 SUITE 3301
FESTUS MO
63028-4137
US

IV. Provider business mailing address

1390 US HIGHWAY 61 SUITE 3301
FESTUS MO
63028-4137
US

V. Phone/Fax

Practice location:
  • Phone: 636-931-6302
  • Fax: 636-933-5055
Mailing address:
  • Phone: 636-931-6302
  • Fax: 636-933-5055

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 Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL STEVE ECKENFELS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 636-933-1107