Provider Demographics
NPI:1558783217
Name:ST. ANTHONY'S PHYSICIAN ORGANIZATION
Entity Type:Organization
Organization Name:ST. ANTHONY'S PHYSICIAN ORGANIZATION
Other - Org Name:MERCY CLINIC SOUTH PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO EAST COMMUNITIES & SFO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MATEJKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-251-1958
Mailing Address - Street 1:714 GRAVOIS RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-7723
Mailing Address - Country:US
Mailing Address - Phone:636-717-6777
Mailing Address - Fax:314-525-1028
Practice Address - Street 1:714 GRAVOIS RD
Practice Address - Street 2:SUITE 220
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-7723
Practice Address - Country:US
Practice Address - Phone:636-717-6777
Practice Address - Fax:314-525-1028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015644OtherMEDICARE PTAN