MEDICARE: K M B S C

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0581522929	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1902867997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	K M B S C

Provider Business Mailing Address
First Line	:	PO BOX 790129
Second Line	:
City	:	ST LOUIS
State	:	MO
Zip	:	63179-0129
Country	:	US
Telephone Number	:	217-464-2966
Fax Number	:	217-464-3193

Provider Business Practice Location Address
First Line	:	1800 E LAKE SHORE DR
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62521-3883
Country	:	US
Telephone Number	:	217-464-2966
Fax Number	:	217-464-3193

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SUE A STRAYER
Credential	:	MD
Telephone Number	:	217-464-2966

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	01/07/2015

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Directions to “K M B S C ” Practice Location

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