Basic Information
| Provider Information | |||||||||
| NPI: | 1376804898 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOREST PARK NEUROLOGY, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3431 S STATE ROUTE 291 | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640572341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166001816 | ||||||||
| FaxNumber: | 8167956966 | ||||||||
| Practice Location | |||||||||
| Address1: | 3431 S STATE ROUTE 291 | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640572341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166001816 | ||||||||
| FaxNumber: | 8167956966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2012 | ||||||||
| LastUpdateDate: | 05/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | DONATO | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | LOURDES | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8166001816 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2008002407 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00002924638 07 | 01 | MO | UNITED HEALTHCARE PROVIDER | OTHER |