Provider Demographics
NPI:1225019318
Name:SURGICAL DIAGNOSTICS & THERAPY LLC
Entity Type:Organization
Organization Name:SURGICAL DIAGNOSTICS & THERAPY LLC
Other - Org Name:KENNETH J BENNETT MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-569-2626
Mailing Address - Street 1:PO BOX 411220
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-1220
Mailing Address - Country:US
Mailing Address - Phone:314-569-2626
Mailing Address - Fax:314-569-1711
Practice Address - Street 1:675 OLD BALLAS RD
Practice Address - Street 2:STE 100A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7083
Practice Address - Country:US
Practice Address - Phone:314-569-2626
Practice Address - Fax:314-569-1711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4131208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A10802Medicare UPIN