Provider Demographics
NPI:1053687079
Name:NEUROSURGICAL SPECIALISTS OF WEST COUNTY INC
Entity Type:Organization
Organization Name:NEUROSURGICAL SPECIALISTS OF WEST COUNTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:GENISIO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:314-251-6364
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 297A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6364
Mailing Address - Fax:314-251-7897
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 297A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6364
Practice Address - Fax:314-251-7897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012027914363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty