Healthcare Provider Details

I. General information

NPI: 1700026515
Provider Name (Legal Business Name): TATYANA PETROSOVA, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2009
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 Number
License Number State

VIII. Authorized Official

Name: TATYANA PETROSOVA
Title or Position: OWNER
Credential: M.D.
Phone: 147-977-0743