Healthcare Provider Details

I. General information

NPI: 1023094836
Provider Name (Legal Business Name): ENDOSCOPY CENTER OF ST. LOUIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BREVCO PLAZA SUITE 207
LAKE SAINT LOUIS MO
63367
US

IV. Provider business mailing address

200 BREVCO PLZ SUITE 207
LAKE SAINT LOUIS MO
63367-2947
US

V. Phone/Fax

Practice location:
  • Phone: 636-561-5450
  • Fax: 636-561-5451
Mailing address:
  • Phone: 636-561-5450
  • Fax: 636-561-5451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number152-0
License Number StateMO

VIII. Authorized Official

Name: JAMES H. PETERSEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 636-561-5450