Provider Demographics
NPI:1750497319
Name:SAINT ANTHONY'S PHYSICIAN GROUP
Entity Type:Organization
Organization Name:SAINT ANTHONY'S PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE-PRESIDENT/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-463-5616
Mailing Address - Street 1:2 SAINT ANTHONYS WAY STE 205
Mailing Address - Street 2:PO BOX 1083
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4569
Mailing Address - Country:US
Mailing Address - Phone:618-462-2222
Mailing Address - Fax:618-462-1150
Practice Address - Street 1:2 SAINT ANTHONYS WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4569
Practice Address - Country:US
Practice Address - Phone:618-462-2222
Practice Address - Fax:618-463-5004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0006021087OtherBLUE SHIELD
ILCD0408Medicare PIN
IL384230Medicare PIN