Provider Demographics
NPI:1376902932
Name:BJC
Entity Type:Organization
Organization Name:BJC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF NURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JIM
Authorized Official - Last Name:VREDENBURGH
Authorized Official - Suffix:III
Authorized Official - Credentials:BSN
Authorized Official - Phone:573-268-2749
Mailing Address - Street 1:92 ROTTINGHAM CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3685
Mailing Address - Country:US
Mailing Address - Phone:573-268-2749
Mailing Address - Fax:
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6163
Practice Address - Country:US
Practice Address - Phone:314-653-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001004428282N00000X
IL041.392442282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital