1154484673 NPI number — MIRIAM B RODIN MD

Table of content: MIRIAM B RODIN MD (NPI 1154484673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154484673 NPI number — MIRIAM B RODIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODIN
Provider First Name:
MIRIAM
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154484673
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1008 S SPRING AVE FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63110-2520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-977-8462
Provider Business Mailing Address Fax Number:
314-771-8575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 S GRAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63104-1016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-977-8462
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X , with the licence number:  2007030792 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: 036076819 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036076819 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".