Healthcare Provider Details

I. General information

NPI: 1992940407
Provider Name (Legal Business Name): MIDWEST NEUROSURGEONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 DOCTORS PARK STE A
CAPE GIRARDEAU MO
63703-4927
US

IV. Provider business mailing address

65 DOCTORS PARK STE A
CAPE GIRARDEAU MO
63703-4927
US

V. Phone/Fax

Practice location:
  • Phone: 573-651-1687
  • Fax: 573-651-8734
Mailing address:
  • Phone: 573-651-1687
  • Fax: 573-651-8734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SONJAY JOSEPH FONN
Title or Position: SINGLE MEMBER/OWNER
Credential: D.O.
Phone: 573-651-1687