=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134572340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINCENT BOSTON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2016
-----------------------------------------------------
Last Update Date | 11/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MEDICAL PLZ
-----------------------------------------------------
City | LAKE ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63367-1366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-625-5200
-----------------------------------------------------
Fax | 636-625-5314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29373 NETWORK PL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60673-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-390-5900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 01089795A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 2018010703
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 036151193
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------