Basic Information
| Provider Information | |||||||||
| NPI: | 1972793610 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAY SPINE LLC | ||||||||
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| OtherOrganizationName: | GATEWAY SPINE EUREKA OFFICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31698 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631310698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 THE LEGENDS PKWY | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630253821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369381600 | ||||||||
| FaxNumber: | 6369381610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2007 | ||||||||
| LastUpdateDate: | 07/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | REINSEL | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3149936170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.