Healthcare Provider Details

I. General information

NPI: 1083684468
Provider Name (Legal Business Name): ADRIANA M CANAS-POLESEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 SMIZER MILL RD STE 106
FENTON MO
63026-3483
US

IV. Provider business mailing address

1203 SMIZER MILL RD STE 106
FENTON MO
63026-3483
US

V. Phone/Fax

Practice location:
  • Phone: 636-717-1390
  • Fax: 636-717-1395
Mailing address:
  • Phone: 636-717-1390
  • Fax: 636-717-1395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2004022976
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: