1093992679 NPI number — DR. MARISSA OMURTAG M.D.

Table of content: DR. MARISSA OMURTAG M.D. (NPI 1093992679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093992679 NPI number — DR. MARISSA OMURTAG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OMURTAG
Provider First Name:
MARISSA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DECASTRO
Provider Other First Name:
MARISSA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093992679
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
339 CONSORT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-4439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-386-9224
Provider Business Mailing Address Fax Number:
636-200-4243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 S NEW BALLAS RD
Provider Second Line Business Practice Location Address:
DEPT. OF ANESTHESIA
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141-8221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-251-4687
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2008

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: 207L00000X , with the licence number:  002828 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 2011013954 , 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)