Provider Demographics
NPI:1881707644
Name:ST LOUIS ORTHOPEDIC INSTITUTE INC
Entity type:Organization
Organization Name:ST LOUIS ORTHOPEDIC INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:ODEGARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-966-0111
Mailing Address - Street 1:12813 FLUSHING MEADOWS DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-543-2123
Mailing Address - Fax:314-966-1023
Practice Address - Street 1:12855 NORTH FORTY DRIVE
Practice Address - Street 2:SUITE 125
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-543-2123
Practice Address - Fax:314-966-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010630Medicare ID - Type Unspecified