Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | 32102 | MO |
NPI | 1366521551 |
---|---|
Provider Name | Dr. Thomas V Cradock |
First Address | Saint Louis, MO 63141-8232 |
Second Address | Saint Louis, MO 63141-8232 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A10874 | (02) | MO |