MEDICARE: ST. JOSEPH'S HEALTH CENTER WOMEN'S AND CHILDREN'S SERVICES CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	2006023270	MO
2	207RP1001X	Pulmonary Disease Physician	2006023270	MO

General Provider Information

NPI Number	:	1518006956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JOSEPH'S HEALTH CENTER WOMEN'S AND CHILDREN'S SERVICES CLINIC

Provider Business Mailing Address
First Line	:	1836 LACKLAND HILL PKWY
Second Line	:	ATTN CREDENTIALING DEPT
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3572
Country	:	US
Telephone Number	:	314-989-0300
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 MEDICAL DR
Second Line	:	SUITE 209
City	:	WENTZVILLE
State	:	MO
Zip	:	63385-3426
Country	:	US
Telephone Number	:	636-332-8482
Fax Number	:

Authorized Official
Title or Position	:	NETWORK VICE PRESIDENT
Name	:	DIANNE P. BARRY
Credential	:
Telephone Number	:	314-989-2180

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	10/17/2007

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