Healthcare Provider Details

I. General information

NPI: 1417286519
Provider Name (Legal Business Name): ST. ANTHONY'S PHYSICIAN ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD SUITE 255
SAINT LOUIS MO
63128-3201
US

IV. Provider business mailing address

12700 SOUTHFORK RD SUITE 255
SAINT LOUIS MO
63128-3201
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1545
  • Fax: 314-525-1685
Mailing address:
  • Phone: 314-525-1545
  • Fax: 314-525-1685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2009033148
License Number StateMO

VIII. Authorized Official

Name: MR. JOHN HINKLE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-525-5988