Provider Demographics
NPI:1871574525
Name:PLISCO, IRWIN (MD)
Entity type:Individual
Prefix:
First Name:IRWIN
Middle Name:
Last Name:PLISCO
Suffix:
Gender:M
Credentials:MD
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 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-839-4554
Mailing Address - Fax:314-837-0047
Practice Address - Street 1:1224 GRAHAM RD
Practice Address - Street 2:SUITE 2003
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8028
Practice Address - Country:US
Practice Address - Phone:314-839-4554
Practice Address - Fax:314-837-0047
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8E05207R00000X
IA24734207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO127484OtherGHP
MO0400525OtherUHC
MO102101OtherHEALTHLINK
MO4040631OtherAETNA
MO6400OtherBCBS
MOC04130OtherEXCLUSIVE CHOICE
MO000000010029OtherESSENCE
MO000000012461OtherESSENCE ST CHARLES
MO2267138OtherAETNA US
MOA10442OtherMERCY
MO4040631OtherAETNA
MO2267138OtherAETNA US
MO000000010029OtherESSENCE