Provider Demographics
NPI:1114969144
Name:SWANSON, ROBERT GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GORDON
Last Name:SWANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385
Mailing Address - Country:US
Mailing Address - Phone:636-327-1201
Mailing Address - Fax:
Practice Address - Street 1:6420 CLAYTON RD.
Practice Address - Street 2:ST. MARY'S HEALTH CENTER
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1850
Practice Address - Country:US
Practice Address - Phone:314-768-8267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK211172085R0001X
NY2511572085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03076684Medicaid
OK100003180BMedicaid
OK920007163OtherRR MEDICARE
OKTHERR104Medicare ID - Type Unspecified
OK100003180BMedicaid
NYA400016545Medicare PIN
OK920007163OtherRR MEDICARE