MEDICARE: RICHARD M DIVALERIO 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	207RR0500X	Rheumatology Physician	R7J89	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	660001262	OTHER	MO	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	27044	OTHER	MO	AETNA
2	288523	OTHER	MO	HEALTHLINK
3	5178116	OTHER	MO	AENTA
5	2541	OTHER	MO	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1841298072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD M DIVALERIO M.D.

Provider Business Mailing Address
First Line	:	3009 N BALLAS RD
Second Line	:	SUITE 100B
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-2322
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3009 N BALLAS RD
Second Line	:	SUITE 100B
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-2322
Country	:	US
Telephone Number	:	314-432-1111
Fax Number	:

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

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	01/08/2014

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Directions to “ RICHARD M DIVALERIO M.D.” Practice Location

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