MEDICARE: DR. THOMAS J VITALE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	R9749	MO
2	208600000X	Surgery Physician	36097734	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	020024920	OTHER	MO	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588643712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS J VITALE M.D.

Provider Business Mailing Address
First Line	:	10777 SUNSET OFFICE DR
Second Line	:	SUITE 300
City	:	SAINT LOUIS
State	:	MO
Zip	:	63127-1019
Country	:	US
Telephone Number	:	314-822-5900
Fax Number	:	314-822-5919

Provider Business Practice Location Address
First Line	:	1031 BELLEVUE AVE
Second Line	:	SUITE 300
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1818
Country	:	US
Telephone Number	:	314-644-6300
Fax Number	:	314-644-2503

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2006
Last Update Date	:	11/24/2008

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