Healthcare Provider Details

I. General information

NPI: 1023089562
Provider Name (Legal Business Name): TATYANA PETROSOVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 06/09/2024
Certification Date: 06/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10420 OLD OLIVE STREET RD STE 305
SAINT LOUIS MO
63141-5914
US

IV. Provider business mailing address

PO BOX 653
CHESTERFIELD MO
63006-0653
US

V. Phone/Fax

Practice location:
  • Phone: 314-797-7074
  • Fax: 314-227-5505
Mailing address:
  • Phone: 314-797-7074
  • Fax: 314-227-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2002007108
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036107203
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: