Basic Information
| Provider Information | |||||||||
| NPI: | 1205877800 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE AMERSON | ||||||||
| FirstName: | MARVINA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3015 N BALLAS RD | ||||||||
| Address2: | ANESTHESIOLOGY DEPARTMENT - 2ND FL | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149965330 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3015 N BALLAS RD | ||||||||
| Address2: | ANESTHESIOLOGY DEPARTMENT - 2ND FL | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149965330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/28/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 02756 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 200601640 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 033561 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 2856 | OK | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 13461 | MS | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1205877800 | 05 | MO | MEDICAID |