MEDICARE: DONNA T. THACKREY 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	208000000X	Pediatrics Physician	106364	MO

General Provider Information

NPI Number	:	1942260484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA T. THACKREY M.D.

Provider Business Mailing Address
First Line	:	2740 S HIGHWAY 94
Second Line	:	SUITE A
City	:	SAINT PETERS
State	:	MO
Zip	:	63303-5609
Country	:	US
Telephone Number	:	636-441-5437
Fax Number	:	636-441-4398

Provider Business Practice Location Address
First Line	:	2740 S HIGHWAY 94
Second Line	:	SUITE A
City	:	SAINT PETERS
State	:	MO
Zip	:	63303-5609
Country	:	US
Telephone Number	:	636-441-5437
Fax Number	:	636-441-4398

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

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	02/01/2012

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