Provider Demographics
NPI:1790788941
Name:BACKER, ROBERT J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:BACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:STE 297A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6364
Mailing Address - Fax:314-251-7897
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:STE 297A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6364
Practice Address - Fax:314-251-7897
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR3D60174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOO06214OtherEXCLUSIVE CHOICE
MO43755OtherGROUP HEALTH PLAN
MO132437OtherHEALTHLINK
MO5810OtherBLUE CROSS BLUE SHIELD
MO0600013OtherUNITED HEALTHCARE
MO431725782OtherTAX ID #
MO140005147OtherMEDICARE RAILROAD
261839808OtherTAX ID
156380004Medicare PIN
MO43755OtherGROUP HEALTH PLAN