Provider Demographics
NPI:1629414644
Name:ST LOUIS SINUS & SLEEP CENTERS, LLC
Entity Type:Organization
Organization Name:ST LOUIS SINUS & SLEEP CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KETAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-939-4368
Mailing Address - Street 1:1167 FORTUNE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7377
Mailing Address - Country:US
Mailing Address - Phone:618-628-0715
Mailing Address - Fax:
Practice Address - Street 1:509 HAMACHER ST
Practice Address - Street 2:SUITE 205
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-4368
Practice Address - Fax:888-371-4468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101869261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic