Healthcare Provider Details

I. General information

NPI: 1588662803
Provider Name (Legal Business Name): BOONSLICK MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BJC SAINT PETERS DR SUITE 100
SAINT PETERS MO
63376-3091
US

IV. Provider business mailing address

201 BJC SAINT PETERS DR SUITE 100
SAINT PETERS MO
63376-3091
US

V. Phone/Fax

Practice location:
  • Phone: 636-916-8228
  • Fax: 636-946-5774
Mailing address:
  • Phone: 636-916-8228
  • Fax: 636-946-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number430954457
License Number StateMO

VIII. Authorized Official

Name: ROBERT B CUSWORTH
Title or Position: PRESIDENT, BOONSLICK MED.GROUP INC
Credential: MD
Phone: 636-916-8228