Provider Demographics
NPI:1568853018
Name:ST ANTHONY'S PHYSICIAN ORGANIZATION OF ILLINOIS
Entity Type:Organization
Organization Name:ST ANTHONY'S PHYSICIAN ORGANIZATION OF ILLINOIS
Other - Org Name:ST ANTHONY'S AT WATERLOO OB/GYN SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:VENUTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-525-7340
Mailing Address - Street 1:509 HAMACHER ST
Mailing Address - Street 2:STE 203
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1592
Mailing Address - Country:US
Mailing Address - Phone:618-939-0575
Mailing Address - Fax:618-939-0577
Practice Address - Street 1:509 HAMACHER ST
Practice Address - Street 2:STE 203
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-0575
Practice Address - Fax:618-939-0577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty