Healthcare Provider Details

I. General information

NPI: 1992776801
Provider Name (Legal Business Name): INTERNAL MEDICINE CONSULTANTS II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 N NEW BALLAS RD SUITE 299
SAINT LOUIS MO
63141-6831
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 314-569-1090
  • Fax: 314-569-1424
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR6A89
License Number StateMO

VIII. Authorized Official

Name: DR. MATTHEW BOSNER
Title or Position: DELEGATED OFFICIAL
Credential: MD
Phone: 314-569-1090