Provider Demographics
NPI:1114113388
Name:ST. ANTHONY'S PHYSICIAN ORGANIZATION PRIVATE PRACTICES LC
Entity Type:Organization
Organization Name:ST. ANTHONY'S PHYSICIAN ORGANIZATION PRIVATE PRACTICES LC
Other - Org Name:EDMOND NG, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:HINKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-543-5903
Mailing Address - Street 1:10004 KENNERLY RD
Mailing Address - Street 2:STE 292B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-525-1224
Mailing Address - Fax:314-525-4957
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:STE 292B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-525-1224
Practice Address - Fax:314-525-4957
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. ANTHONY'S PHYSICIAN ORGANIZATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-20
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015653Medicare PIN