Healthcare Provider Details

I. General information

NPI: 1164720041
Provider Name (Legal Business Name): INFECTIOUS DISEASE PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

PO BOX 1413
O FALLON IL
62269-8413
US

V. Phone/Fax

Practice location:
  • Phone: 636-333-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number2004025502
License Number StateMO

VIII. Authorized Official

Name: RAJEEV DEWAN
Title or Position: PRESIDENT
Credential: MD
Phone: 636-333-4500