Basic Information
| Provider Information | |||||||||
| NPI: | 1902862634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASADY | ||||||||
| FirstName: | ROGER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 505164 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631505164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 CARTER ST | ||||||||
| Address2: | |||||||||
| City: | BERRYVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726164303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704233338 | ||||||||
| FaxNumber: | 8704237330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 10/02/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | E-3204 | AR | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1902862634 | 05 | MO | MEDICAID | 5M086C895 | 01 | AR | AR MCR GROUP #5C895 | OTHER | 145897001 | 05 | AR | MEDICAID | P00653981 | 01 | RAILROAD MEDICARE | OTHER |