Provider Demographics
NPI:1962675744
Name:BOONSLICK PEDIATRICS
Entity Type:Organization
Organization Name:BOONSLICK PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOBONC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-441-4144
Mailing Address - Street 1:5600 MEXICO RD STE 21
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1660
Mailing Address - Country:US
Mailing Address - Phone:636-441-4144
Mailing Address - Fax:636-441-4112
Practice Address - Street 1:5600 MEXICO RD STE 21
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1660
Practice Address - Country:US
Practice Address - Phone:636-441-4144
Practice Address - Fax:636-441-4112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7C25305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization