Provider Demographics
NPI:1588643712
Name:VITALE, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:VITALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10777 SUNSET OFFICE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1019
Mailing Address - Country:US
Mailing Address - Phone:314-822-5900
Mailing Address - Fax:314-822-5919
Practice Address - Street 1:1031 BELLEVUE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1818
Practice Address - Country:US
Practice Address - Phone:314-644-6300
Practice Address - Fax:314-644-2503
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2008-11-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR9749208600000X
IL36097734208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO020024920OtherRAILROAD MEDICARE
MO201920816Medicaid
MO991373012Medicare PIN
MOD50877Medicare UPIN
MO020024920OtherRAILROAD MEDICARE