Provider Demographics
NPI:1750461067
Name:THE ORTHOPEDIC CENTER OF ST. LOUIS
Entity Type:Organization
Organization Name:THE ORTHOPEDIC CENTER OF ST. LOUIS
Other - Org Name:MFG SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIALS
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-336-2620
Mailing Address - Street 1:14825 N OUTER 40
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2152
Mailing Address - Country:US
Mailing Address - Phone:314-336-2555
Mailing Address - Fax:314-336-2557
Practice Address - Street 1:14825 N OUTER 40
Practice Address - Street 2:SUITE 200
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2152
Practice Address - Country:US
Practice Address - Phone:314-336-2555
Practice Address - Fax:314-336-2557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36909174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF27083Medicare UPIN