Provider Demographics
NPI:1417286519
Name:ST. ANTHONY'S PHYSICIAN ORGANIZATION
Entity Type:Organization
Organization Name:ST. ANTHONY'S PHYSICIAN ORGANIZATION
Other - Org Name:BREAST SURGEONS OF SOUTH COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HINKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-525-5988
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:SUITE 255
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:314-525-1545
Mailing Address - Fax:314-525-1685
Practice Address - Street 1:12700 SOUTHFORK RD
Practice Address - Street 2:SUITE 255
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3201
Practice Address - Country:US
Practice Address - Phone:314-525-1545
Practice Address - Fax:314-525-1685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009033148208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H28169Medicare UPIN