Provider Demographics
NPI:1538313424
Name:ST PETERS BONE AND JOINT SURGERY, INC
Entity Type:Organization
Organization Name:ST PETERS BONE AND JOINT SURGERY, INC
Other - Org Name:ST PETERS BONE AND JOINT
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:P
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-229-4239
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-0008
Mailing Address - Country:US
Mailing Address - Phone:636-441-3444
Mailing Address - Fax:636-441-9832
Practice Address - Street 1:1601 WENTZVILLE PKWY
Practice Address - Street 2:SUITE 117
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3814
Practice Address - Country:US
Practice Address - Phone:636-441-3444
Practice Address - Fax:636-441-9832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207X00000X
332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0596770002Medicare NSC