Provider Demographics
NPI:1356393011
Name:MIRKIN, RHODERIC PETER (MD)
Entity type:Individual
Prefix:DR
First Name:RHODERIC
Middle Name:PETER
Last Name:MIRKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:12122 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-1772
Practice Address - Country:US
Practice Address - Phone:314-849-0808
Practice Address - Fax:314-849-8983
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO109865207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO136643OtherGROUP HEALTH PLAN
MO200046096OtherRAILROAD MEDICARE
MO0900210OtherUNITED HEALTHCARE
MO2102999001OtherCIGNA
MO26919OtherBLUE CROSS BLUE SHIELD
MO951747OtherAETNA
MO283694OtherHEALTHLINK
MO0900210OtherUNITED HEALTHCARE
MO200046096OtherRAILROAD MEDICARE