Provider Demographics
NPI:1407218365
Name:ST ANTHONYS PHYSICIAN ORGANIZATION OF ILLINOIS
Entity type:Organization
Organization Name:ST ANTHONYS PHYSICIAN ORGANIZATION OF ILLINOIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-525-1053
Mailing Address - Street 1:9735 LANDMARK PARKWAY DR
Mailing Address - Street 2:STE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1646
Mailing Address - Country:US
Mailing Address - Phone:314-543-5999
Mailing Address - Fax:314-543-6836
Practice Address - Street 1:211 S BURNS AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1895
Practice Address - Country:US
Practice Address - Phone:314-543-5999
Practice Address - Fax:314-543-5994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty