Provider Demographics
NPI:1043512999
Name:ST. LOUIS BREAST CENTER LLC
Entity Type:Organization
Organization Name:ST. LOUIS BREAST CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MUCKERMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:314-409-2108
Mailing Address - Street 1:884 WOODS MILL RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3657
Mailing Address - Country:US
Mailing Address - Phone:636-779-8008
Mailing Address - Fax:
Practice Address - Street 1:884 WOODS MILL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3657
Practice Address - Country:US
Practice Address - Phone:636-779-8008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography