=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396923694
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. LUKE'S WHC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2008
-----------------------------------------------------
Last Update Date | 02/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 N NEW BALLAS RD SUITE 250
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-6835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-567-4449
-----------------------------------------------------
Fax | 314-567-0762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | NW 5946 P.O. BOX 1450
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55485-5946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-542-8553
-----------------------------------------------------
Fax | 952-513-6880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER (SECRETARY)
-----------------------------------------------------
Name | DONALD D. JACOBSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-543-6500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------