1770504250 NPI number — PHILIP C TROTTA M.D.

Table of content: PHILIP C TROTTA M.D. (NPI 1770504250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770504250 NPI number — PHILIP C TROTTA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TROTTA
Provider First Name:
PHILIP
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1770504250
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 411515
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:
63141-3515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-333-6750
Provider Business Mailing Address Fax Number:
314-432-0178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13303 TESSON FERRY 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:
63128-4062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-843-5888
Provider Business Practice Location Address Fax Number:
314-843-1905
Provider Enumeration Date:
07/21/2006

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: 2085R0202X , with the licence number:  32168 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: 036053242 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036053242 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200664902 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300099726 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 300102465 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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