1619960606 NPI number — SAMER THANAVARO MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619960606 NPI number — SAMER THANAVARO MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

THANAVARO

Provider First Name:

SAMER

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1619960606

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/02/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

11125 DUNN RD

Provider Second Line Business Mailing Address:

SUITE 204

Provider Business Mailing Address City Name:

SAINT LOUIS

Provider Business Mailing Address State Name:

MO

Provider Business Mailing Address Postal Code:

63136-6132

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

314-839-5522

Provider Business Mailing Address Fax Number:

314-839-5351

Provider First Line Business Practice Location Address:

11125 DUNN RD

Provider Second Line Business Practice Location Address:

SUITE 204

Provider Business Practice Location Address City Name:

SAINT LOUIS

Provider Business Practice Location Address State Name:

MO

Provider Business Practice Location Address Postal Code:

63136-6132

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

314-839-5522

Provider Business Practice Location Address Fax Number:

314-839-5351

Provider Enumeration Date:

08/25/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RC0000X , with the licence number:  036072313 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RC0000X , with the licence number: R6765 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 060067960 . This is a "ILRRMCR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: 110099256 . This is a "MORRMCR" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
• Identifier: 431098908 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 2500083 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
• Identifier: A13504 . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
• Identifier: 2333V3831 . This is a "GHP/CMR" identifier . This identifiers is of the category "OTHER".
• Identifier: 000000012939 . This is a "ESSENCE" identifier . This identifiers is of the category "OTHER".
• Identifier: 7268V8816 . This is a "HCUSA" identifier . This identifiers is of the category "OTHER".
• Identifier: 200998417 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
• Identifier: 119171 . This is a "HLNK" identifier . This identifiers is of the category "OTHER".
• Identifier: 1259965 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 43336V30946 . This is a "HLTHPART" identifier . This identifiers is of the category "OTHER".
• Identifier: 4037808 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".