Healthcare Provider Details

I. General information

NPI: 1477058949
Provider Name (Legal Business Name): IAN ROSLAWSKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

42D MEDICAL GROUP, 300 S. TWINING ST BLDG 760
MAXWELL AFB AL
36112
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1000
  • Fax:
Mailing address:
  • Phone: 334-953-3368
  • Fax: 334-953-8607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number2024045914
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: