1477058949 NPI number — IAN ROSLAWSKI DO

Table of content: IAN ROSLAWSKI DO (NPI 1477058949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477058949 NPI number — IAN ROSLAWSKI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSLAWSKI
Provider First Name:
IAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1477058949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
42D MEDICAL GROUP, 300 S. TWINING ST BLDG 760
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAXWELL AFB
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-953-3368
Provider Business Mailing Address Fax Number:
334-953-8607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10010 KENNERLY RD
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:
63128-2106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-525-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2018

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: 207QA0505X , with the licence number:  2024045914 , 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)





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