1790788941 NPI number — DR. ROBERT J BACKER MD

Table of content: DR. ROBERT J BACKER MD (NPI 1790788941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790788941 NPI number — DR. ROBERT J BACKER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACKER
Provider First Name:
ROBERT
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1790788941
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
621 S NEW BALLAS RD
Provider Second Line Business Mailing Address:
STE 297A
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-8232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-251-6364
Provider Business Mailing Address Fax Number:
314-251-7897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 S NEW BALLAS RD
Provider Second Line Business Practice Location Address:
STE 297A
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141-8232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-251-6364
Provider Business Practice Location Address Fax Number:
314-251-7897
Provider Enumeration Date:
05/23/2005

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: 174400000X , with the licence number:  MDR3D60 , 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: O06214 . This is a "EXCLUSIVE CHOICE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 43755 . This is a "GROUP HEALTH PLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 132437 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 5810 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0600013 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 431725782 . This is a "TAX ID #" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 140005147 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 261839808 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".




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