Basic Information
| Provider Information | |||||||||
| NPI: | 1649280793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REMYNSE | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | CLARENCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 955860 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631959359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364985944 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 GOOD SAMARITAN WAY STE 420 | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628642478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188994000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 4301055819 | MI | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 042.0012584 | VT | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 080172 | GA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 036150216 | 01 | IL | LICENSE | OTHER | 1021499 | 05 | VT | MEDICAID | 2750986 | 05 | MI | MEDICAID | OVN3891 | 01 | VT | CVMC-MEDICAID | OTHER | VN3891 | 01 | VT | CVMC-MEDICARE | OTHER |