Provider Demographics
NPI:1225182157
Name:ST PETERS BONE & JOINT SURGERY INC
Entity Type:Organization
Organization Name:ST PETERS BONE & JOINT SURGERY INC
Other - Org Name:ADVANCED BONE & JOINT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-441-3444
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-0008
Mailing Address - Country:US
Mailing Address - Phone:636-441-3444
Mailing Address - Fax:636-441-9832
Practice Address - Street 1:112 PIPER HILL DR
Practice Address - Street 2:SUITE 9
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1690
Practice Address - Country:US
Practice Address - Phone:636-441-3444
Practice Address - Fax:636-441-9832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 207XS0117X, 207XX0004X
MO332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0596770001Medicare NSC