Provider Demographics
NPI:1053691709
Name:S&J OF SOUTH COUNTY LLC
Entity type:Organization
Organization Name:S&J OF SOUTH COUNTY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-302-0736
Mailing Address - Street 1:10 LONG MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-3014
Mailing Address - Country:US
Mailing Address - Phone:314-302-0736
Mailing Address - Fax:
Practice Address - Street 1:11188 TESSON FERRY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6962
Practice Address - Country:US
Practice Address - Phone:636-717-6717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-26
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001009169207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144262825OtherNPI