Provider Demographics
NPI:1932491263
Name:ST ANTHONY'S PHYSICIAN ORGANIZATION SPECIALTY SERVICES LLC
Entity Type:Organization
Organization Name:ST ANTHONY'S PHYSICIAN ORGANIZATION SPECIALTY SERVICES LLC
Other - Org Name:ST. ANTHONY'S LONG TERM CARE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-525-1153
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:314-525-1887
Mailing Address - Fax:314-525-1868
Practice Address - Street 1:12700 SOUTHFORK RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3201
Practice Address - Country:US
Practice Address - Phone:314-525-1887
Practice Address - Fax:314-525-1868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3810OtherMEDICARE PTAN
MOMA3809OtherMEDICARE PTAN