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NPI Code Detail

MEDICARE: MARANATHA HEALTHCARE PC

MEDICARE: MARANATHA HEALTHCARE PC
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
1208D00000XGeneral Practice PhysicianR7F89MO
2208VP0000XPain Medicine PhysicianR7F89MO
3208G00000XThoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianR7F89MO

General Provider Information

NPI Number : 1679896716
Entity Type Code : Organization
Provider Name (Legal Business Name) : MARANATHA HEALTHCARE PC
Provider Business Mailing Address
First Line : PO BOX 3980
Second Line :
City : CHESTERFIELD
State : MO
Zip : 63006-3980
Country : US
Telephone Number : 314-522-1888
Fax Number : 314-522-9674
Provider Business Practice Location Address
First Line : 9231 W FLORISSANT AVE
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63136-1422
Country : US
Telephone Number : 314-522-1888
Fax Number : 314-522-9674
Authorized Official
Title or Position : PRESIDENT
Name : DR. ADELUOLA G LIPEDE
Credential : M.D.
Telephone Number : 314-522-1888
Provider Enumeration Date : 03/03/2010
Last Update Date : 05/17/2010

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1225866858 — MPWER
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Directions to “MARANATHA HEALTHCARE PC ” Practice Location

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