1720248065 NPI number — MISSOURI MEDICAL PARTNERS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720248065 NPI number — MISSOURI MEDICAL PARTNERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSOURI MEDICAL PARTNERS 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:
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:
1720248065
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 504683
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:
63150-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-333-4500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 BOWLES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63026-2394
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:
636-333-4510
Provider Enumeration Date:
06/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MILOSAVLJEVIC
Authorized Official First Name:
VLADIMIR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-484-0842

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  2003015147 , 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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