Provider Demographics
NPI:1255546990
Name:NEUROMAR
Entity type:Organization
Organization Name:NEUROMAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ZEVALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-931-6090
Mailing Address - Street 1:166 INDUSTRIAL DR.
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028
Mailing Address - Country:US
Mailing Address - Phone:636-931-6090
Mailing Address - Fax:636-933-9509
Practice Address - Street 1:166 INDUSTRIAL DR.
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028
Practice Address - Country:US
Practice Address - Phone:636-931-6090
Practice Address - Fax:636-933-9509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001608872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504599309Medicaid
MODF9044OtherRAILROAD MEDICARE PIN
MODF9044OtherRAILROAD MEDICARE PIN
MOH37967Medicare UPIN