Provider Demographics
NPI:1043609324
Name:ST. ANTHONY'S PHYSICIAN ORGANIZATION
Entity Type:Organization
Organization Name:ST. ANTHONY'S PHYSICIAN ORGANIZATION
Other - Org Name:MERCY CLINIC SOUTH PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO EAST COMMUNITIES & SFO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MATEJKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-251-1958
Mailing Address - Street 1:9735 LANDMARK PARKWAY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1666
Mailing Address - Country:US
Mailing Address - Phone:314-525-1887
Mailing Address - Fax:314-525-1868
Practice Address - Street 1:723 S LACLEDE STATION RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-4911
Practice Address - Country:US
Practice Address - Phone:314-446-2303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015644OtherMEDICARE GROUP PTAN