1376804898 NPI number — FOREST PARK NEUROLOGY, 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 1376804898 NPI number — FOREST PARK NEUROLOGY, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOREST PARK NEUROLOGY, 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:
1376804898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3431 S STATE ROUTE 291
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64057-2341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-600-1816
Provider Business Mailing Address Fax Number:
816-795-6966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3431 S STATE ROUTE 291
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64057-2341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-600-1816
Provider Business Practice Location Address Fax Number:
816-795-6966
Provider Enumeration Date:
05/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DONATO
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
LOURDES
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
816-600-1816

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  2008002407 , 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: 00002924638 07 . This is a "UNITED HEALTHCARE PROVIDER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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