Healthcare Provider Details

I. General information

NPI: 1144372491
Provider Name (Legal Business Name): ORTHOPEDIC & SPORTS MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S KIRKWOOD RD SUITE 120
SAINT LOUIS MO
63122-7254
US

IV. Provider business mailing address

PO BOX 843857
KANSAS CITY MO
64184-3857
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-8887
  • Fax: 314-966-3869
Mailing address:
  • Phone: 314-966-8887
  • Fax: 314-966-3869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TONY ROSSO
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-966-8887