Provider Demographics
NPI:1104953660
Name:ST. LOUIS EYE CLINIC
Entity type:Organization
Organization Name:ST. LOUIS EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SCIORTINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-352-9800
Mailing Address - Street 1:4530 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2238
Mailing Address - Country:US
Mailing Address - Phone:314-352-9800
Mailing Address - Fax:314-352-4290
Practice Address - Street 1:1145 E GANNON DR
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-2611
Practice Address - Country:US
Practice Address - Phone:314-352-9800
Practice Address - Fax:314-352-4290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
MOMDR4D74156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0624310007Medicare NSC