Provider Demographics
NPI:1225225279
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:ST ANTHONY'S GASTROENTEROLOGY
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. 364B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-543-5911
Mailing Address - Fax:314-543-5914
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:STE. 364B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-543-5911
Practice Address - Fax:314-543-5914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8411207R00000X
207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015654Medicare PIN