Provider Demographics
NPI:1649041666
Name:ORTHOPEDIC CENTER OF ST LOUIS IMG LLC
Entity type:Organization
Organization Name:ORTHOPEDIC CENTER OF ST LOUIS IMG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KILEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-336-2555
Mailing Address - Street 1:14825 N OUTER 40 RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2152
Mailing Address - Country:US
Mailing Address - Phone:314-336-2555
Mailing Address - Fax:314-336-2557
Practice Address - Street 1:14825 N OUTER 40 RD STE 200
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2152
Practice Address - Country:US
Practice Address - Phone:314-336-2555
Practice Address - Fax:314-336-2557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty