Provider Demographics
NPI: | 1164077822 |
---|---|
Name: | FAMILY MEDICINE - SLMG SOUTH, LLC |
Entity Type: | Organization |
Organization Name: | FAMILY MEDICINE - SLMG SOUTH, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | VP PHYSICIAN NETWORK |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JAMES |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SNIDER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 636-685-7804 |
Mailing Address - Street 1: | 121 SAINT LUKES CENTER DR |
Mailing Address - Street 2: | |
Mailing Address - City: | CHESTERFIELD |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63017-3518 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 636-685-7804 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1501 PROFESSIONAL DR |
Practice Address - Street 2: | |
Practice Address - City: | IMPERIAL |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63052-3809 |
Practice Address - Country: | US |
Practice Address - Phone: | 636-464-4000 |
Practice Address - Fax: | 636-529-0699 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | ST. LUKES MEDICAL GROUP |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2019-08-08 |
Last Update Date: | 2020-10-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |