=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194065268
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. LOUIS AMBULATORY ANESTHESIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2013
-----------------------------------------------------
Last Update Date | 03/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14705 WHITE LANE CT
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-7955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-559-2666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5930 ROYAL LN STE E #350
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75230-3896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-559-2666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOE SLIMACK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 314-575-1745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------