Provider Demographics
NPI:1952181216
Name:STEADFAST SPINE AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:STEADFAST SPINE AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COSGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-359-4663
Mailing Address - Street 1:1190 JEFFERSON ST STE 203
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4443
Mailing Address - Country:US
Mailing Address - Phone:636-283-0328
Mailing Address - Fax:
Practice Address - Street 1:1190 JEFFERSON ST STE 203
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4443
Practice Address - Country:US
Practice Address - Phone:636-283-0328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center