Provider Demographics
NPI:1306891551
Name:NORTHWEST INFECTIOUS DISEASE SERVICES LLC
Entity type:Organization
Organization Name:NORTHWEST INFECTIOUS DISEASE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:G
Authorized Official - Last Name:ZINSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-291-7997
Mailing Address - Street 1:PO BOX 776874
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6874
Mailing Address - Country:US
Mailing Address - Phone:314-291-7997
Mailing Address - Fax:314-739-1471
Practice Address - Street 1:12774 BOENKER LN
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-291-7997
Practice Address - Fax:314-739-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507780401Medicaid