Basic Information
| Provider Information | |||||||||
| NPI: | 1962553933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REINKER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5 | ||||||||
| Address2: | |||||||||
| City: | HAZELWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630420005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148953828 | ||||||||
| FaxNumber: | 6369225157 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633761659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148953828 | ||||||||
| FaxNumber: | 6369225157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 04/29/2011 | ||||||||
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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 | 367500000X | 155412 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 916151715 | 05 | MO | MEDICAID | P00165057 | 01 | MO | RAILROAD MEDICARE | OTHER |