Healthcare Provider Details

I. General information

NPI: 1497088082
Provider Name (Legal Business Name): ST. ANTHONY'S PHYSICIAN ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD STE 200 & 220
SAINT LOUIS MO
63128-3201
US

IV. Provider business mailing address

12700 SOUTHFORK RD STE.200 & 220
SAINT LOUIS MO
63128-3201
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5942
  • Fax: 314-543-5947
Mailing address:
  • Phone: 314-543-5942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number106241
License Number StateMO

VIII. Authorized Official

Name: MS. CHERYL MATEJKA
Title or Position: CFO EAST COMMUNITIES & SFO
Credential:
Phone: 314-251-1958