=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972666162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOONSLICK MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 BOONES LICK RD
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63301-2463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-916-8228
-----------------------------------------------------
Fax | 636-946-5774
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 BOONES LICK RD
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63301-2463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-916-8228
-----------------------------------------------------
Fax | 636-946-5774
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, BOONSLICK MED. GROUP INC
-----------------------------------------------------
Name | ROBERT B CUSWORTH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 636-947-3392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------