=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003231002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MYSOREKAR SURGICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2014
-----------------------------------------------------
Last Update Date | 04/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8342 DELCREST DR APT 303
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63124-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-359-5648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8342 DELCREST DR APT 303
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63124-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-359-5648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. RAJEEV NAGARAJ MYSOREKAR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 314-359-5648
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 108329
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------