Provider Demographics
NPI:1992934012
Name:ST MARY'S HEALTH CENTER
Entity type:Organization
Organization Name:ST MARY'S HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR INTERNAL MEDICINE
Authorized Official - Prefix:
Authorized Official - First Name:MOREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-768-8778
Mailing Address - Street 1:4571 GIBSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1519
Mailing Address - Country:US
Mailing Address - Phone:314-534-6303
Mailing Address - Fax:
Practice Address - Street 1:6420 CLAYTON RD
Practice Address - Street 2:ST MARY'S HEALTH CENTER
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1811
Practice Address - Country:US
Practice Address - Phone:314-768-8778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009006291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty