Healthcare Provider Details

I. General information

NPI: 1962675744
Provider Name (Legal Business Name): BOONSLICK PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 MEXICO RD STE 21
SAINT PETERS MO
63376-1660
US

IV. Provider business mailing address

5600 MEXICO RD STE 21
SAINT PETERS MO
63376-1660
US

V. Phone/Fax

Practice location:
  • Phone: 636-441-4144
  • Fax: 636-441-4112
Mailing address:
  • Phone: 636-441-4144
  • Fax: 636-441-4112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberR7C25
License Number StateMO

VIII. Authorized Official

Name: DR. ROBERT J LOBONC
Title or Position: MD
Credential:
Phone: 636-441-4144