Provider Demographics
NPI:1902867997
Name:K M B S C
Entity Type:Organization
Organization Name:K M B S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:A
Authorized Official - Last Name:STRAYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-464-2966
Mailing Address - Street 1:PO BOX 790129
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-0129
Mailing Address - Country:US
Mailing Address - Phone:217-464-2966
Mailing Address - Fax:217-464-3193
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3883
Practice Address - Country:US
Practice Address - Phone:217-464-2966
Practice Address - Fax:217-464-3193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0581522929OtherBCBS
IL0581522929OtherBCBS