Provider Demographics
NPI:1841917309
Name:AHS MISSOURI MEDICAL GROUP LLC
Entity type:Organization
Organization Name:AHS MISSOURI MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BURKET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-666-0602
Mailing Address - Street 1:505 N BRAND BLVD STE 1110
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-3932
Mailing Address - Country:US
Mailing Address - Phone:818-666-0602
Mailing Address - Fax:
Practice Address - Street 1:3933 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-4601
Practice Address - Country:US
Practice Address - Phone:818-666-0602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center