Provider Demographics
NPI: | 1932580271 |
---|---|
Name: | MOLLER, ALYSSA RENEE (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ALYSSA |
Middle Name: | RENEE |
Last Name: | MOLLER |
Suffix: | |
Gender: | F |
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 60352 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAINT LOUIS |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63160-0352 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 314-362-1700 |
Mailing Address - Fax: | 314-362-9878 |
Practice Address - Street 1: | 1 BARNES JEWISH HOSPITAL PLZ |
Practice Address - Street 2: | DIV IM HOSPITALIST |
Practice Address - City: | SAINT LOUIS |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63110-1003 |
Practice Address - Country: | US |
Practice Address - Phone: | 314-362-1700 |
Practice Address - Fax: | 314-362-9878 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2015-06-12 |
Last Update Date: | 2024-04-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2021008349 | 207R00000X, 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 200096669 | Medicaid |