Provider Demographics
NPI:1639204696
Name:ST. LOUIS THORACIC AND VASCULAR INC
Entity Type:Organization
Organization Name:ST. LOUIS THORACIC AND VASCULAR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:KRAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-543-5939
Mailing Address - Street 1:10004 KENNERLY RD
Mailing Address - Street 2:SUTIE 186B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-543-5939
Mailing Address - Fax:
Practice Address - Street 1:10004 KENNERLY RD STE 186B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2176
Practice Address - Country:US
Practice Address - Phone:314-543-5939
Practice Address - Fax:314-543-5954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO31077174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501942809Medicaid
MO501942809Medicaid