Healthcare Provider Details

I. General information

NPI: 1154571776
Provider Name (Legal Business Name): CLAYTON PRIMARY CARE GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 09/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD SUITE 300 A
SAINT LOUIS MO
63131-2322
US

IV. Provider business mailing address

3009 N BALLAS RD SUITE 300 A
SAINT LOUIS MO
63131-2322
US

V. Phone/Fax

Practice location:
  • Phone: 314-872-9900
  • Fax: 314-872-3939
Mailing address:
  • Phone: 314-872-9900
  • Fax: 314-872-3939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: J COLLINS CORDER
Title or Position: OWNER/PARTNER
Credential: M D
Phone: 314-872-9900