Provider Demographics
NPI:1336258177
Name:LIONELLI, GERALD (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:LIONELLI
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:PO BOX 419074
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9074
Mailing Address - Country:US
Mailing Address - Phone:314-843-0900
Mailing Address - Fax:314-843-0904
Practice Address - Street 1:224 S WOODS MILL RD
Practice Address - Street 2:SUITE 450 SOUTH
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3513
Practice Address - Country:US
Practice Address - Phone:314-843-0900
Practice Address - Fax:314-843-0904
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2002010427208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200001907Medicaid
MO200001907Medicaid
MOH63956Medicare UPIN