Provider Demographics
NPI:1215378955
Name:MIDWEST NEUROSURGEONS, LLC
Entity Type:Organization
Organization Name:MIDWEST NEUROSURGEONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SONJAY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FONN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-651-1687
Mailing Address - Street 1:PO BOX 614
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0614
Mailing Address - Country:US
Mailing Address - Phone:573-651-1687
Mailing Address - Fax:573-651-8734
Practice Address - Street 1:2901 UNION RD STE 200
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-3972
Practice Address - Country:US
Practice Address - Phone:314-626-3602
Practice Address - Fax:314-310-3894
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST NEUROSURGEONS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-10
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1992940407Medicaid
IL118789550Medicaid