Provider Demographics
NPI:1801831045
Name:ST LOUIS CARDIOLOGY CONSULTANTS LTD
Entity Type:Organization
Organization Name:ST LOUIS CARDIOLOGY CONSULTANTS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMER
Authorized Official - Middle Name:
Authorized Official - Last Name:THANAVARO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-433-1861
Mailing Address - Street 1:2 MEMORIAL DR STE 106
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6723
Mailing Address - Country:US
Mailing Address - Phone:618-433-1861
Mailing Address - Fax:618-433-9274
Practice Address - Street 1:2 MEMORIAL DR STE 106
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6723
Practice Address - Country:US
Practice Address - Phone:618-433-1861
Practice Address - Fax:618-433-9274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3831OtherCMR / GHP
ILCJ3315OtherILRRMCR
1020549OtherCAREPARTNERS
MO500347406Medicaid
MOC50434OtherMORRMCR
219678300OtherOWCP
8816OtherHC USA
IL2629958OtherBC/BS
30946OtherHEALTH PARTNERS
MOC50434OtherMORRMCR
1020549OtherCAREPARTNERS