Provider Demographics
NPI:1750681151
Name:SOUTH ST LOUIS MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:SOUTH ST LOUIS MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMLESH
Authorized Official - Middle Name:C
Authorized Official - Last Name:VYAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-881-0300
Mailing Address - Street 1:PO BOX 445
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-0445
Mailing Address - Country:US
Mailing Address - Phone:888-371-0337
Mailing Address - Fax:888-371-0337
Practice Address - Street 1:3824 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1237
Practice Address - Country:US
Practice Address - Phone:314-881-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2979Medicare PIN