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General NPI Number Information
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NPI Number | 1023089562
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Entity Type | Individual
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Provider Name | TATYANA PETROSOVA MD
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Gender | Female
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Dates
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Enumeration Date | 02/01/2006
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Last Update Date | 06/09/2024
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Provider Practice Location Address
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Address Line | 10420 OLD OLIVE STREET RD STE 305
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City | SAINT LOUIS
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State | MO
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Zip | 63141-5914
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Country | US
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Telephone | 314-797-7074
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Fax | 314-227-5505
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Provider Business Mailing Address
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Address Line | PO BOX 653
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City | CHESTERFIELD
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State | MO
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Zip | 63006-0653
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Country | US
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Telephone | 314-797-7074
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Fax | 314-227-5505
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 2002007108
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 036107203
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License Number State | IL
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