MEDICARE: DR. ROSEMARY LOUISE CANNISTRARO M.D. PHD

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	207R00000X	Internal Medicine Physician	100907	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00257143	OTHER	MO	RR MEDICARE

General Provider Information

NPI Number	:	1790739241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROSEMARY LOUISE CANNISTRARO M.D. PHD

Provider Business Mailing Address
First Line	:	11550 OLIVE BLVD
Second Line	:	STE 140
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-7111
Country	:	US
Telephone Number	:	314-205-8344
Fax Number	:	314-590-5931

Provider Business Practice Location Address
First Line	:	11550 OLIVE BLVD
Second Line	:	STE 140
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-7111
Country	:	US
Telephone Number	:	314-205-8344
Fax Number	:	314-590-5931

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	10/27/2011

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