Provider Demographics
NPI:1255747267
Name:AMARA PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:AMARA PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:L.
Authorized Official - Middle Name:C
Authorized Official - Last Name:TUNSTALL-ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-361-0477
Mailing Address - Street 1:5615 PERSHING AVE
Mailing Address - Street 2:SUITE 26
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-1757
Mailing Address - Country:US
Mailing Address - Phone:314-361-0477
Mailing Address - Fax:314-361-3771
Practice Address - Street 1:5615 PERSHING AVE
Practice Address - Street 2:SUITE 26
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-1757
Practice Address - Country:US
Practice Address - Phone:314-361-0477
Practice Address - Fax:314-361-3771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-058285207R00000X
MO35725207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty