=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518105097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | XRT II, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2009
-----------------------------------------------------
Last Update Date | 01/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 S TRUMAN BLVD SUITE D
-----------------------------------------------------
City | CRYSTAL CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63019-1728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-937-5111
-----------------------------------------------------
Fax | 636-937-5777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 S TRUMAN BLVD SUITE D
-----------------------------------------------------
City | CRYSTAL CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63019-1728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-937-5111
-----------------------------------------------------
Fax | 636-937-5777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. MARY W CONTI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 618-632-5501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | R5635
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------