Provider Demographics
NPI:1972666162
Name:BOONSLICK MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BOONSLICK MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, BOONSLICK MED. GROUP INC
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:CUSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-947-3392
Mailing Address - Street 1:1301 BOONES LICK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2463
Mailing Address - Country:US
Mailing Address - Phone:636-916-8228
Mailing Address - Fax:636-946-5774
Practice Address - Street 1:1301 BOONES LICK RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2463
Practice Address - Country:US
Practice Address - Phone:636-916-8228
Practice Address - Fax:636-946-5774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty