Provider Demographics
NPI:1538298054
Name:PULMONARY DIAGNOSTIC & THERAPEUTIC SERVICES, INC.
Entity Type:Organization
Organization Name:PULMONARY DIAGNOSTIC & THERAPEUTIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-362-7276
Mailing Address - Street 1:3263 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1618
Mailing Address - Country:US
Mailing Address - Phone:314-362-7276
Mailing Address - Fax:618-452-3288
Practice Address - Street 1:4625 LINDELL BLVD
Practice Address - Street 2:SUITE 507
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3725
Practice Address - Country:US
Practice Address - Phone:314-362-7276
Practice Address - Fax:618-452-3288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4525207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200845816Medicaid
A10973Medicare UPIN
MO000004080Medicare ID - Type Unspecified