Basic Information
| Provider Information | |||||||||
| NPI: | 1003914953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMERO | ||||||||
| FirstName: | ALFREDO | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 622 COLLINS DR | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630282077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366381506 | ||||||||
| FaxNumber: | 6366381507 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 E SONTERRA BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782584238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105461410 | ||||||||
| FaxNumber: | 2105461419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 12/04/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | R3417 | TX | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | R3417 | TX | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000769503 | 01 | MO | BCBSMO | OTHER | 13003914953 | 05 | MO | MEDICAID |