Provider Demographics
NPI:1215916432
Name:CERNY, ROGER G (CRNA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:G
Last Name:CERNY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22407
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-0407
Mailing Address - Country:US
Mailing Address - Phone:636-386-7222
Mailing Address - Fax:636-386-7810
Practice Address - Street 1:11133 DUNN ROAD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6119
Practice Address - Country:US
Practice Address - Phone:314-923-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO065267367500000X
IL209000686367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO918913807Medicaid
P00415481OtherRR MEDICARE
$$$$$$$$$OtherHEALTHNET/TRICARE
P00415481OtherRR MEDICARE
MO836074814Medicare PIN
P00415481OtherRR MEDICARE
ILK44424Medicare PIN