Organization
IMAGE, EAR, NOSE & THROAT SURGERY, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KEITH A. BONACQUISTI MD (PRESIDENT)
(636) 937-2388
Entity
Organization
Contact information
Practice address
1151 GANNON DRIVE EAST, FESTUS, MO 63028-2611
(636) 937-2388
(636) 937-4976
Mailing address
1151 GANNON DRIVE EAST, FESTUS, MO 63028-2611
(636) 937-2388
(636) 937-4976
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
109503
MO
Other
Enumeration date
05/06/2010
Last updated
05/14/2010
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