Healthcare Provider Details

I. General information

NPI: 1215378955
Provider Name (Legal Business Name): MIDWEST NEUROSURGEONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 10/26/2024
Certification Date: 10/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 UNION RD STE 100
SAINT LOUIS MO
63125-3972
US

IV. Provider business mailing address

PO BOX 614
CAPE GIRARDEAU MO
63702-0614
US

V. Phone/Fax

Practice location:
  • Phone: 314-408-0129
  • Fax: 314-408-0141
Mailing address:
  • Phone: 573-651-1687
  • Fax: 573-651-8734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SONJAY JOSEPH FONN
Title or Position: OWNER
Credential: DO
Phone: 314-408-0129