Provider Demographics
NPI:1215468491
Name:SAINT LOUIS UNIVERSITY
Entity type:Organization
Organization Name:SAINT LOUIS UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKHOLD
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:314-577-8762
Mailing Address - Street 1:1402 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1004
Mailing Address - Country:US
Mailing Address - Phone:314-577-8762
Mailing Address - Fax:
Practice Address - Street 1:3660 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2540
Practice Address - Country:US
Practice Address - Phone:314-977-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT LOUIS UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty