Provider Demographics
NPI:1316128846
Name:VASCULAR SURGERY OF ST. LOUIS P.C.
Entity type:Organization
Organization Name:VASCULAR SURGERY OF ST. LOUIS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:CHAMBERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-750-0935
Mailing Address - Street 1:2355 DOUGHERTY FERRY RD
Mailing Address - Street 2:SUITE 440
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3325
Mailing Address - Country:US
Mailing Address - Phone:314-614-8775
Mailing Address - Fax:314-983-9559
Practice Address - Street 1:2355 DOUGHERTY FERRY RD
Practice Address - Street 2:SUITE 440
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3325
Practice Address - Country:US
Practice Address - Phone:314-614-8775
Practice Address - Fax:314-983-9559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7H292086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202643524Medicaid
MOB96435Medicare UPIN
MO202643524Medicaid