Provider Demographics
NPI:1194972125
Name:THOMAS R WHALEN MD LLC
Entity type:Organization
Organization Name:THOMAS R WHALEN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-878-0163
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:TOWER A SUITE 537
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-336-9141
Mailing Address - Fax:314-336-9148
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:TOWER A SUITE 537
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-336-9141
Practice Address - Fax:314-336-9148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101052207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF77138Medicare UPIN