Healthcare Provider Details

I. General information

NPI: 1871574525
Provider Name (Legal Business Name): IRWIN PLISCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 GRAHAM RD SUITE 2003
FLORISSANT MO
63031-8028
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 314-839-4554
  • Fax: 314-837-0047
Mailing address:
  • Phone: 314-839-4554
  • Fax: 314-837-0047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR8E05
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number24734
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: