Provider Demographics
NPI:1992776801
Name:INTERNAL MEDICINE CONSULTANTS II, LLC
Entity type:Organization
Organization Name:INTERNAL MEDICINE CONSULTANTS II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-569-1090
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:456 N NEW BALLAS RD
Practice Address - Street 2:SUITE 299
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6831
Practice Address - Country:US
Practice Address - Phone:314-569-1090
Practice Address - Fax:314-569-1424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6A89207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501466205Medicaid
MOCP7862OtherRR MEDICARE GROUP#
MO000012849Medicare PIN