Provider Demographics
NPI:1831202431
Name:SAINT LUKES HOSPITAL OF TRENTON
Entity type:Organization
Organization Name:SAINT LUKES HOSPITAL OF TRENTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-358-5700
Mailing Address - Street 1:189 IOWA BLVD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683-8343
Mailing Address - Country:US
Mailing Address - Phone:660-358-5750
Mailing Address - Fax:660-358-5740
Practice Address - Street 1:301 W 2ND ST
Practice Address - Street 2:
Practice Address - City:JAMESPORT
Practice Address - State:MO
Practice Address - Zip Code:64648-8208
Practice Address - Country:US
Practice Address - Phone:660-684-6244
Practice Address - Fax:660-684-6246
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT LUKES HOSPITAL OF TRENTON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO99778363LF0000X
MODOR9350208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO508190006Medicaid
268643Medicare Oscar/Certification
MO7760000BMedicare PIN