MEDICARE: DR. FRED ROANLD MONTERUBIO JR. 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	207V00000X	Obstetrics & Gynecology Physician	R9A68	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	07-00217	OTHER		MEDICARE COMPLETE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	5143	OTHER	HEALTHCARE USA
2	46318	OTHER	GROUP HEALTH PLAN
4	0700217	OTHER	UNITED HEALTH CARE
5	SP15678	OTHER	CIGNA
6	101340	OTHER	HEALTHLINK
7	112759	OTHER	BLUE CROSS BLUE SHIELD
8	4217036	OTHER	AETNA

General Provider Information

NPI Number	:	1962400143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FRED ROANLD MONTERUBIO JR. M.D.

Provider Business Mailing Address
First Line	:	3009 N BALLAS RD
Second Line	:	STE 356C
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-2322
Country	:	US
Telephone Number	:	314-432-2880
Fax Number	:	314-432-4810

Provider Business Practice Location Address
First Line	:	3009 N BALLAS RD
Second Line	:	STE 356C
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-2322
Country	:	US
Telephone Number	:	314-432-2880
Fax Number	:	314-432-4810

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

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	07/08/2007

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Directions to “ DR. FRED ROANLD MONTERUBIO JR. M.D.” Practice Location

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