1447629464 NPI number — MS. IRENE MARION RATHJEN PNP

Table of content: MS. IRENE MARION RATHJEN PNP (NPI 1447629464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447629464 NPI number — MS. IRENE MARION RATHJEN PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RATHJEN
Provider First Name:
IRENE
Provider Middle Name:
MARION
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447629464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60352
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63160-0352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-454-6093
Provider Business Mailing Address Fax Number:
844-965-9624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CHILDRENS PL
Provider Second Line Business Practice Location Address:
DIV PED GENETICS AND GENOMIC MED
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63110-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-454-6093
Provider Business Practice Location Address Fax Number:
844-965-9624
Provider Enumeration Date:
09/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  2015016091 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 420033957 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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