Provider Demographics
NPI:1619960606
Name:THANAVARO, SAMER (MD)
Entity Type:Individual
Prefix:
First Name:SAMER
Middle Name:
Last Name:THANAVARO
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 1:11125 DUNN RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6132
Mailing Address - Country:US
Mailing Address - Phone:314-839-5522
Mailing Address - Fax:314-839-5351
Practice Address - Street 1:11125 DUNN RD
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6132
Practice Address - Country:US
Practice Address - Phone:314-839-5522
Practice Address - Fax:314-839-5351
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072313207RC0000X
MOR6765207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL060067960OtherILRRMCR
MO110099256OtherMORRMCR
431098908OtherTRICARE
2500083OtherUHC
A13504OtherMERCY
2333V3831OtherGHP/CMR
000000012939OtherESSENCE
7268V8816OtherHCUSA
MO200998417Medicaid
119171OtherHLNK
1259965OtherCIGNA
43336V30946OtherHLTHPART
4037808OtherAETNA
000000012939OtherESSENCE
ILL87313Medicare PIN
A13504OtherMERCY
4037808OtherAETNA
1259965OtherCIGNA
2333V3831OtherGHP/CMR
MO004011207Medicare PIN