Provider Demographics
NPI:1174742720
Name:SPECIALTY AND PRIMARY CARE LLC
Entity type:Organization
Organization Name:SPECIALTY AND PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ZAFAR
Authorized Official - Middle Name:
Authorized Official - Last Name:QUADER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-842-6333
Mailing Address - Street 1:10004 KENNERLY RD
Mailing Address - Street 2:257 A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-842-6333
Mailing Address - Fax:314-543-5271
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:257 A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-842-6333
Practice Address - Fax:314-543-5271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109425207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361744184Medicaid
MO208721902Medicaid
MODA8910OtherRAILROAD MEDICARE
MO000012699Medicare PIN
IL361744184Medicaid