Provider Demographics
NPI:1043548506
Name:EDWARDO D VERZOLA MD PC
Entity type:Organization
Organization Name:EDWARDO D VERZOLA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDWARDO
Authorized Official - Middle Name:D
Authorized Official - Last Name:VERZOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-937-8675
Mailing Address - Street 1:1004 HERCULANEUM INDUSTRIAL DR
Mailing Address - Street 2:P O BOX 127
Mailing Address - City:HERCULANEUM
Mailing Address - State:MO
Mailing Address - Zip Code:63048-1507
Mailing Address - Country:US
Mailing Address - Phone:636-937-8675
Mailing Address - Fax:636-933-1981
Practice Address - Street 1:1004 HERCULANEUM INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:HERCULANEUM
Practice Address - State:MO
Practice Address - Zip Code:63048-1507
Practice Address - Country:US
Practice Address - Phone:636-937-8675
Practice Address - Fax:636-933-1981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161966207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00094938OtherMEDICARE PROVIDER #
MO2000161966OtherMO LICENSE
MOVE205099708Medicaid
10856311OtherCAQH
MOVE205099708Medicaid