Basic Information
| Provider Information | |||||||||
| NPI: | 1548357163 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRACTICE OF ALAN SPIVACK, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 S WOODS MILL RD | ||||||||
| Address2: | ATTN: RICK SONNE | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145762490 | ||||||||
| FaxNumber: | 3145762473 | ||||||||
| Practice Location | |||||||||
| Address1: | 224 S WOODS MILL RD | ||||||||
| Address2: | SUITE 620 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145761610 | ||||||||
| FaxNumber: | 3145761859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | SONNE | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3145762490 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. LUKE'S MEDICAL GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 29603 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1121155230 | 01 | MO | RAILROAD MEDICARE | OTHER |