Basic Information
Provider Information | |||||||||
NPI: | 1124009022 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BYRNE | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23340 | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631563340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3147394166 | ||||||||
FaxNumber: | 3147392485 | ||||||||
Practice Location | |||||||||
Address1: | 12255 DE PAUL DR | ||||||||
Address2: | SUITE 700 | ||||||||
City: | BRIDGETON | ||||||||
State: | MO | ||||||||
PostalCode: | 630442510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3147394166 | ||||||||
FaxNumber: | 3147392485 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2005 | ||||||||
LastUpdateDate: | 09/21/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R1J78 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0400915 | 01 | MO | UHC | OTHER | 202580312 | 05 | MO |   | MEDICAID | 11011 | 01 | MO | BCBS | OTHER | 5241272 | 01 | MO | AETNA | OTHER | B18388 | 01 | MO | MERCY | OTHER | 000000010010 | 01 | MO | ESSENCE | OTHER | 000000012459 | 01 | MO | ESSENCE ST CHARLES | OTHER | 127465 | 01 |   | GHP | OTHER | D04003 | 01 | MO | EXCLUSIVE CHOICE | OTHER | 0403000 | 01 |   | UHC MEDICARE COMPLETE | OTHER | 165438 | 01 |   | HEALTHLINK | OTHER | 165438 | 01 | MO | HEALTHLINK | OTHER |