Provider Demographics
NPI:1205877800
Name:MOORE AMERSON, MARVINA (DO)
Entity type:Individual
Prefix:
First Name:MARVINA
Middle Name:
Last Name:MOORE AMERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 N BALLAS RD
Mailing Address - Street 2:ANESTHESIOLOGY DEPARTMENT - 2ND FL
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2329
Mailing Address - Country:US
Mailing Address - Phone:314-996-5330
Mailing Address - Fax:
Practice Address - Street 1:3015 N BALLAS RD
Practice Address - Street 2:ANESTHESIOLOGY DEPARTMENT - 2ND FL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2329
Practice Address - Country:US
Practice Address - Phone:314-996-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02756207L00000X
MO200601640207L00000X
GA033561207L00000X
OK2856207L00000X
MS13461207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1205877800Medicaid
IL$$$$$$$$$OtherHEALTHCARE & FAMILY SERIVCES
MO1205877800Medicaid