MEDICARE: DR. ANTONIO R PENILLA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	33875	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	P00320613	OTHER		RR MCR
3	7480467052	OTHER	IL	IDPA

General Provider Information

NPI Number	:	1265431399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANTONIO R PENILLA M.D.

Provider Business Mailing Address
First Line	:	670 MASON RIDGE CENTER DR
Second Line	:	STE. 300
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8573
Country	:	US
Telephone Number	:	314-953-6300
Fax Number	:	314-953-6309

Provider Business Practice Location Address
First Line	:	1225 GRAHAM RD
Second Line	:	STE 2310C
City	:	FLORISSANT
State	:	MO
Zip	:	63031-8012
Country	:	US
Telephone Number	:	314-953-6300
Fax Number	:	314-953-6309

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	01/30/2013

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Directions to “ DR. ANTONIO R PENILLA M.D.” Practice Location

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