Provider Demographics
NPI:1558531350
Name:ST LOUIS CARDIOLOGY CENTER, PC
Entity Type:Organization
Organization Name:ST LOUIS CARDIOLOGY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:V
Authorized Official - Last Name:DWYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-995-6839
Mailing Address - Street 1:3009 N BALLAS RD
Mailing Address - Street 2:BUILDING B SUITE 202
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2322
Mailing Address - Country:US
Mailing Address - Phone:314-995-6839
Mailing Address - Fax:
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:BUILDING B SUITE 202
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-995-6839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCH3871Medicare PIN
MOCH3870Medicare PIN