Healthcare Provider Details

I. General information

NPI: 1992401954
Provider Name (Legal Business Name): MISSOURI HEART AND VASCULAR CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N NEW BALLAS RD STE 206
SAINT LOUIS MO
63141-6835
US

IV. Provider business mailing address

PO BOX 658
MANCHESTER MO
63011-0958
US

V. Phone/Fax

Practice location:
  • Phone: 314-803-4372
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GHASSAN A ASSI
Title or Position: ADMINISTRATOR
Credential:
Phone: 314-803-4372