Healthcare Provider Details

I. General information

NPI: 1043251549
Provider Name (Legal Business Name): AVIVA H RASKAS, MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8420 DELMAR BLVD 505
SAINT LOUIS MO
63124-2170
US

IV. Provider business mailing address

PO BOX 957723
SAINT LOUIS MO
63195-7723
US

V. Phone/Fax

Practice location:
  • Phone: 314-749-6621
  • Fax: 314-432-0223
Mailing address:
  • Phone: 314-432-2580
  • Fax: 314-432-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2002011264
License Number StateMO

VIII. Authorized Official

Name: MRS. TRACY J PARCIAK
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-432-2580