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General NPI Number Information
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NPI Number | 1326186602
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Entity Type | Organization
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Legal Business Name | CRYSTAL CITY PULMONARY CRITICAL CARE & SLEEP MEDICINE
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 10/21/2014
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Provider Practice Location Address
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Address Line | 1390 US HIGHWAY 61 STE 2300
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City | FESTUS
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State | MO
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Zip | 63028-4121
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Country | US
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Telephone | 636-937-3121
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Fax | 636-937-4423
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Provider Business Mailing Address
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Address Line | 4468 SOUTHVIEW WAY DR
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City | SAINT LOUIS
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State | MO
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Zip | 63129-6718
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Country | US
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Telephone | 636-937-3121
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Fax | 636-937-4423
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | SARAH INGRAM
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Credential | CPC
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Telephone | 636-937-3121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 2004030200
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License Number State | MO
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