Provider Demographics
NPI:1073541728
Name:ST CLAIR ORTHOPEDICS, SC
Entity Type:Organization
Organization Name:ST CLAIR ORTHOPEDICS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-849-0311
Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:33 BRONZE POINTE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-8311
Practice Address - Country:US
Practice Address - Phone:618-257-1177
Practice Address - Fax:618-257-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL263758OtherGROUP HEALTHPLAN
IL761576OtherAETNA
IL761576OtherAETNA