1972793610 NPI number — GATEWAY SPINE LLC

Table of content: (NPI 1972793610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972793610 NPI number — GATEWAY SPINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATEWAY SPINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GATEWAY SPINE EUREKA OFFICE
Provider Other Organization Name Type Code:
5
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:
1972793610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31698
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:
63131-0698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-989-0300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 THE LEGENDS PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63025-3821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-938-1600
Provider Business Practice Location Address Fax Number:
636-938-1610
Provider Enumeration Date:
07/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REINSEL
Authorized Official First Name:
TOM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-993-6170

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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