Healthcare Provider Details

I. General information

NPI: 1306891551
Provider Name (Legal Business Name): NORTHWEST INFECTIOUS DISEASE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12774 BOENKER LN
BRIDGETON MO
63044
US

IV. Provider business mailing address

PO BOX 776874
CHICAGO IL
60677-6874
US

V. Phone/Fax

Practice location:
  • Phone: 314-291-7997
  • Fax: 314-739-1471
Mailing address:
  • Phone: 314-291-7997
  • Fax: 314-739-1471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILLIP G ZINSER
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 314-291-7997