Provider Demographics
NPI:1003027988
Name:ST. LOUIS CENTER FOR PREVENTIVE AND LONGEVITY MEDICINE, LLC
Entity Type:Organization
Organization Name:ST. LOUIS CENTER FOR PREVENTIVE AND LONGEVITY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:BLIGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-994-1536
Mailing Address - Street 1:777 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 200 E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8705
Mailing Address - Country:US
Mailing Address - Phone:314-994-1536
Mailing Address - Fax:314-692-0241
Practice Address - Street 1:777 S NEW BALLAS RD
Practice Address - Street 2:SUITE 200 E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8705
Practice Address - Country:US
Practice Address - Phone:314-994-1536
Practice Address - Fax:314-692-0241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102881207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1306813050OtherINDIVIDUAL NPI NUMBER
MOF92826Medicare UPIN