Provider Demographics
NPI:1023342391
Name:ALLEGIANCE MEDICAL SERVICES
Entity type:Organization
Organization Name:ALLEGIANCE MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:CAMILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-646-8234
Mailing Address - Street 1:2331 HAMPTON AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2908
Mailing Address - Country:US
Mailing Address - Phone:314-646-8234
Mailing Address - Fax:314-646-8349
Practice Address - Street 1:2331 HAMPTON AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-2908
Practice Address - Country:US
Practice Address - Phone:314-646-8234
Practice Address - Fax:314-646-8349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-19
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1023342391Medicaid
IL=========001Medicaid