Provider Demographics
NPI:1992848212
Name:PRACTICE OF ROSEMARY CANNISTRARO, LLC
Entity Type:Organization
Organization Name:PRACTICE OF ROSEMARY CANNISTRARO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SONNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-576-2490
Mailing Address - Street 1:232 S WOODS MILL RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3417
Mailing Address - Country:US
Mailing Address - Phone:314-576-2490
Mailing Address - Fax:314-576-2473
Practice Address - Street 1:12609 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6313
Practice Address - Country:US
Practice Address - Phone:314-205-8344
Practice Address - Fax:314-205-0217
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. LUKE'S MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-15
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODD8725OtherRR MEDICARE