Provider Demographics
NPI:1770504250
Name:TROTTA, PHILIP C (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:C
Last Name:TROTTA
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:PO BOX 411515
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-3515
Mailing Address - Country:US
Mailing Address - Phone:314-333-6750
Mailing Address - Fax:314-432-0178
Practice Address - Street 1:13303 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-4062
Practice Address - Country:US
Practice Address - Phone:314-843-5888
Practice Address - Fax:314-843-1905
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO321682085R0202X
IL0360532422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053242Medicaid
MO200664902Medicaid
MO300099726OtherRAILROAD MEDICARE
MO300102465OtherRAILROAD MEDICARE
MO004013061Medicare ID - Type UnspecifiedMO MEDICARE
ILL79281Medicare ID - Type UnspecifiedIL MEDICARE
MO200664902Medicaid
MO300102465OtherRAILROAD MEDICARE