Provider Demographics
NPI:1720001084
Name:MEDSOURCE OF ST. LOUIS, INC.
Entity Type:Organization
Organization Name:MEDSOURCE OF ST. LOUIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-966-1818
Mailing Address - Street 1:3394 MCKELVEY RD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63044
Mailing Address - Country:US
Mailing Address - Phone:314-966-1818
Mailing Address - Fax:314-966-1001
Practice Address - Street 1:3394 MCKELVEY RD.
Practice Address - Street 2:SUITE 102
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-966-1818
Practice Address - Fax:314-966-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO15710874332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO626012405Medicaid
MO29678OtherBLUE CROSS BLUE SHIELD
MO29678OtherBLUE CROSS BLUE SHIELD