Provider Demographics
NPI:1417126210
Name:ST LOUIS SURGICAL DOCTORS GROUP LLC
Entity Type:Organization
Organization Name:ST LOUIS SURGICAL DOCTORS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-577-5778
Mailing Address - Street 1:548 CLAYMONT PLACE DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2553
Mailing Address - Country:US
Mailing Address - Phone:314-577-5778
Mailing Address - Fax:
Practice Address - Street 1:3535 S JEFFERSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3930
Practice Address - Country:US
Practice Address - Phone:314-577-5778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004034166174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty