Physician Compare National (NPI:1053401422)

HEALTHCARE PROVIDER: GUS THEODOS M.D.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1053401422
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	8729134945
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20160715000279
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	THEODOS
	Individual professional last name
Provider First Name	GUS
	Individual professional first name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	CLVLND CLINIC LERNER COLLEGE OF MED OF CASE WSTN RSV UNIVERSITY
	Individual professional's medical school
Graduation Year	2003
	Individual professional's medical school graduation year
Primary Specialty	INTERVENTIONAL CARDIOLOGY
	Primary medical specialty reported by the individual professional in the selected enrollment
Secondary Specialty 1	CARDIOVASCULAR DISEASE (CARDIOLOGY)
	First secondary medical specialty reported by the individual professional in the selected enrollment
All Secondary Specialties	CARDIOVASCULAR DISEASE (CARDIOLOGY)
	All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas

Practice Information
Organization Legal Name	PHYSICIAN GROUPS LC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	3072421254
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	383
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	3015 N BALLAS RD
	Group Practice or individual's line 1 address
City	SAINT LOUIS
	Group Practice or individual's city
State	MO
	Group Practice or individual's state
Zip Code	631312329
	Group Practice or individual's zip code (9 digits when available)
Phone Number	3149965772
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	260108
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	MISSOURI BAPTIST MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 1
Professional Accepts Medicare Assignment	Y