=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124013487
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUDHIR R RAIKAR M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2005
-----------------------------------------------------
Last Update Date | 02/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 83 PROGRESS PKWY
-----------------------------------------------------
City | MARYLAND HEIGHTS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63043-3701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-434-8174
-----------------------------------------------------
Fax | 314-434-8706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 920 BELLERIVE MANOR DR
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-6094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-434-6841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PP0204X
-----------------------------------------------------
Taxonomy Name | Pediatric Emergency Medicine (Emergency Medicine) Physician
-----------------------------------------------------
License Number | R8500
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------