Basic Information
| Provider Information | |||||||||
| NPI: | 1619960606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THANAVARO | ||||||||
| FirstName: | SAMER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11125 DUNN RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148395522 | ||||||||
| FaxNumber: | 3148395351 | ||||||||
| Practice Location | |||||||||
| Address1: | 11125 DUNN RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148395522 | ||||||||
| FaxNumber: | 3148395351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036072313 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | R6765 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 060067960 | 01 | IL | ILRRMCR | OTHER | 110099256 | 01 | MO | MORRMCR | OTHER | 431098908 | 01 | TRICARE | OTHER | 2500083 | 01 | UHC | OTHER | A13504 | 01 | MERCY | OTHER | 2333V3831 | 01 | GHP/CMR | OTHER | 000000012939 | 01 | ESSENCE | OTHER | 7268V8816 | 01 | HCUSA | OTHER | 200998417 | 05 | MO | MEDICAID | 119171 | 01 | HLNK | OTHER | 1259965 | 01 | CIGNA | OTHER | 43336V30946 | 01 | HLTHPART | OTHER | 4037808 | 01 | AETNA | OTHER |