Basic Information
Provider Information | |||||||||
NPI: | 1992848212 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRACTICE OF ROSEMARY CANNISTRARO, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 232 S WOODS MILL RD | ||||||||
Address2: |   | ||||||||
City: | CHESTERFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 630173417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3145762490 | ||||||||
FaxNumber: | 3145762473 | ||||||||
Practice Location | |||||||||
Address1: | 12609 OLIVE BLVD | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631416313 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3142058344 | ||||||||
FaxNumber: | 3142050217 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2007 | ||||||||
LastUpdateDate: | 11/27/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SONNE | ||||||||
AuthorizedOfficialFirstName: | RICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3145762490 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ST. LUKE'S MEDICAL GROUP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | DD8725 | 01 | MO | RR MEDICARE | OTHER |