Provider Demographics
NPI:1790920023
Name:EXECUTIVE NEUROPSYCHIATRIC SYSTEMS INCORPORATED
Entity Type:Organization
Organization Name:EXECUTIVE NEUROPSYCHIATRIC SYSTEMS INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:MINCHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-367-3050
Mailing Address - Street 1:225 S MERAMEC AVE
Mailing Address - Street 2:SUITE 1221T
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3511
Mailing Address - Country:US
Mailing Address - Phone:314-367-3050
Mailing Address - Fax:314-367-3712
Practice Address - Street 1:225 S MERAMEC AVE
Practice Address - Street 2:SUITE 1221T
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-3511
Practice Address - Country:US
Practice Address - Phone:314-367-3050
Practice Address - Fax:314-367-3712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD1021462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000095333OtherMEDICARE IDENTIFICATION NUMBER
MO10853441OtherCAQH IDENTIFICATION NUMBER
MOF84428Medicare UPIN