=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538339841
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TESSON HEIGHTS ORTHOPEDIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2008
-----------------------------------------------------
Last Update Date | 08/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12152 TESSON FERRY RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-714-1023
-----------------------------------------------------
Fax | 314-714-1068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12152 TESSON FERRY RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-714-1023
-----------------------------------------------------
Fax | 314-714-1068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING DEPARTMENT SUPERVISOR
-----------------------------------------------------
Name | SHERRI L RAINWATER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-849-5414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------