Provider Demographics
NPI:1023094836
Name:ENDOSCOPY CENTER OF ST. LOUIS
Entity type:Organization
Organization Name:ENDOSCOPY CENTER OF ST. LOUIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-561-5450
Mailing Address - Street 1:200 BREVCO PLZ
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-2947
Mailing Address - Country:US
Mailing Address - Phone:636-561-5450
Mailing Address - Fax:636-561-5451
Practice Address - Street 1:200 BREVCO PLAZA
Practice Address - Street 2:SUITE 207
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367
Practice Address - Country:US
Practice Address - Phone:636-561-5450
Practice Address - Fax:636-561-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO152-0261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00214935OtherRAIL ROAD MEDICARE
MO195965OtherBCBS