Provider Demographics
NPI:1104432640
Name:COMPLEX HEALTHCARE OF DES PERES LLC
Entity type:Organization
Organization Name:COMPLEX HEALTHCARE OF DES PERES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-692-6313
Mailing Address - Street 1:6040 CAMP BOWIE BLVD STE 24
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5602
Mailing Address - Country:US
Mailing Address - Phone:817-735-1180
Mailing Address - Fax:
Practice Address - Street 1:1032 OLD DES PERES RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1865
Practice Address - Country:US
Practice Address - Phone:817-735-1180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty