Provider Demographics
NPI:1013329150
Name:PHYSICIAN AFFILIATES OF ST. LUKE'S MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PHYSICIAN AFFILIATES OF ST. LUKE'S MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SONNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-576-2490
Mailing Address - Street 1:121 SAINT LUKES CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3509
Mailing Address - Country:US
Mailing Address - Phone:314-576-2490
Mailing Address - Fax:314-576-2344
Practice Address - Street 1:121 SAINT LUKES CENTER DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3518
Practice Address - Country:US
Practice Address - Phone:314-576-2475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. LUKE'S MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty