=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801008396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETER FONSECA MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 01/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10004 KENNERLY SUITE 345A
-----------------------------------------------------
City | ST. LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-543-5252
-----------------------------------------------------
Fax | 314-543-5211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10004 KENNERLY SUITE 345A
-----------------------------------------------------
City | ST. LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-543-5252
-----------------------------------------------------
Fax | 314-543-5211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PETER FONSECA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 314-543-5252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 116658
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------