=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265962609
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLE BURKHARTSMEIER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2017
-----------------------------------------------------
Last Update Date | 02/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3635 VISTA AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63110-2539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-577-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3635 VISTA AVENUE EMERGENCY MEDICINE OFFICES
-----------------------------------------------------
City | ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 2017018433
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------