Provider Demographics
NPI:1265751119
Name:RALKO, ADAM M (MD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:M
Last Name:RALKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 DES PERES RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2050
Mailing Address - Country:US
Mailing Address - Phone:314-821-1313
Mailing Address - Fax:
Practice Address - Street 1:1000 DES PERES RD
Practice Address - Street 2:SUITE 310
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-2050
Practice Address - Country:US
Practice Address - Phone:314-821-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096219390200000X
MO2013027441207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01241117OtherRAILROAD MEDICARE
MOP01241117OtherRAILROAD MEDICARE