=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215378955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST NEUROSURGEONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2013
-----------------------------------------------------
Last Update Date | 10/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 UNION RD STE 100
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63125-3972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-408-0129
-----------------------------------------------------
Fax | 314-408-0141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 614
-----------------------------------------------------
City | CAPE GIRARDEAU
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63702-0614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-651-1687
-----------------------------------------------------
Fax | 573-651-8734
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SONJAY JOSEPH FONN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 314-408-0129
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------