Organization
ENDOSCOPY CENTER OF ST. LOUIS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JAMES H. PETERSEN M.D. (PRESIDENT)
(636) 561-5450
Entity
Organization
Contact information
Practice address
200 BREVCO PLAZA, SUITE 207, LAKE SAINT LOUIS, MO 63367
(636) 561-5450
(636) 561-5451
Mailing address
200 BREVCO PLZ, SUITE 207, LAKE SAINT LOUIS, MO 63367-2947
(636) 561-5450
(636) 561-5451
Taxonomy
Speciality
Code
Description
License number
State
261QE0800X
Endoscopy Clinic/Center
Primary
152-0
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
195965
BCBS
MO
01
—
P00214935
RAIL ROAD MEDICARE
MO
Enumeration date
12/22/2005
Last updated
11/27/2007
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