Basic Information
| Provider Information | |||||||||
| NPI: | 1447201868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACEREN | ||||||||
| FirstName: | RODOLFO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 HOWE XING | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630284044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369331000 | ||||||||
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| Practice Location | |||||||||
| Address1: | HWY 61S AT HWY 67 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369331000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | R6445 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | BM0858932 | 01 | DEA | OTHER | 24219 | 01 | MO | CDS | OTHER |