1003841388 NPI number — DR. LAWRENCE VINCENT BOVERI MD

Table of content: DR. LAWRENCE VINCENT BOVERI MD (NPI 1003841388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003841388 NPI number — DR. LAWRENCE VINCENT BOVERI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOVERI
Provider First Name:
LAWRENCE
Provider Middle Name:
VINCENT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOVERI
Provider Other First Name:
LAWRENCE
Provider Other Middle Name:
VINCENT
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1003841388
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 BOWLES AVE.
Provider Second Line Business Mailing Address:
SUITE 215
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63028-3287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-680-1960
Provider Business Mailing Address Fax Number:
636-680-1961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 BOWLES AVE
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63026-2395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-680-1960
Provider Business Practice Location Address Fax Number:
636-680-1964
Provider Enumeration Date:
07/12/2006

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: 207V00000X , with the licence number:  R7P94 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 207951500 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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