Basic Information
| Provider Information | |||||||||
| NPI: | 1881604601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAVRANEK | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3691 RUTGER ST | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149776828 | ||||||||
| FaxNumber: | 3179776777 | ||||||||
| Practice Location | |||||||||
| Address1: | 1465 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145775642 | ||||||||
| FaxNumber: | 3142686410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 2006034636 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 208000000X | 2006034636 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.