Provider Demographics
NPI:1902023542
Name:SOUTH CITY HEALTH LLC
Entity Type:Organization
Organization Name:SOUTH CITY HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIMION
Authorized Official - Middle Name:
Authorized Official - Last Name:PRAGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-647-2555
Mailing Address - Street 1:6555 CHIPPEWA ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-4110
Mailing Address - Country:US
Mailing Address - Phone:314-647-2555
Mailing Address - Fax:314-647-2599
Practice Address - Street 1:6555 CHIPPEWA ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-4110
Practice Address - Country:US
Practice Address - Phone:314-647-2555
Practice Address - Fax:314-647-2599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD105478207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F80109Medicare UPIN