Provider Demographics
NPI:1205255247
Name:PASSPORT HEALTH
Entity type:Organization
Organization Name:PASSPORT HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LTANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-997-8100
Mailing Address - Street 1:2025 S BRENTWOOD BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1833
Mailing Address - Country:US
Mailing Address - Phone:314-997-8100
Mailing Address - Fax:314-997-8102
Practice Address - Street 1:2025 S BRENTWOOD BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-1833
Practice Address - Country:US
Practice Address - Phone:314-997-8100
Practice Address - Fax:314-997-8102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service