Basic Information
| Provider Information | |||||||||
| NPI: | 1265639959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZIMOLZAK | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1402 S GRAND BLVD | ||||||||
| Address2: | 12TH FLOOR N DESLOGE TOWERS | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145778000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1402 S GRAND BLVD | ||||||||
| Address2: | 12TH FLOOR N DESLOGE TOWERS | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145778000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 08/13/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2010020878 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2007018524 | 01 | MO | MO STATE LICENSE | OTHER | 622961209 | 05 | MO | MEDICAID |