Provider Demographics
NPI:1053356840
Name:SYLVANOVICH, W. RICHARD (MD)
Entity type:Individual
Prefix:
First Name:W.
Middle Name:RICHARD
Last Name:SYLVANOVICH
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 1:2821 N BALLAS RD
Mailing Address - Street 2:STE 110
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2314
Mailing Address - Country:US
Mailing Address - Phone:314-628-9000
Mailing Address - Fax:314-628-9696
Practice Address - Street 1:2821 N BALLAS RD STE 110
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2314
Practice Address - Country:US
Practice Address - Phone:314-628-9000
Practice Address - Fax:314-628-9696
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036043679207RG0100X
MO33925207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA10893Medicare UPIN