1245294149 NPI number — ROBERT ROSS SMEYNE DO

Table of content: ROBERT ROSS SMEYNE DO (NPI 1245294149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245294149 NPI number — ROBERT ROSS SMEYNE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMEYNE
Provider First Name:
ROBERT
Provider Middle Name:
ROSS
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:
1245294149
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12639 OLD TESSON RD
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63128-2786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-849-0311
Provider Business Mailing Address Fax Number:
314-849-4423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1390 HIGHWAY 61 STE G1000
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FESTUS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63028-4136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-933-7400
Provider Business Practice Location Address Fax Number:
636-933-7403
Provider Enumeration Date:
04/17/2006

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: 207X00000X , with the licence number:  R8366 , 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: 033563002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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