Provider Demographics
NPI:1194950451
Name:ST. LOUIS SPORTS HEALTH, LLC
Entity type:Organization
Organization Name:ST. LOUIS SPORTS HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROTHROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-821-4423
Mailing Address - Street 1:1000 DES PERES RD
Mailing Address - Street 2:SUITE 325
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2050
Mailing Address - Country:US
Mailing Address - Phone:314-821-4423
Mailing Address - Fax:314-821-7706
Practice Address - Street 1:1000 DES PERES RD
Practice Address - Street 2:SUITE 325
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2050
Practice Address - Country:US
Practice Address - Phone:314-821-4423
Practice Address - Fax:314-821-7706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-15
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003010405207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODR3292OtherMEDICARE RAILROAD
MOH84609Medicare UPIN