MEDICARE: MS. BESSEVELYN M. TABLES M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2008016715	MO

General Provider Information

NPI Number	:	1225291248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BESSEVELYN M. TABLES M.D.

Provider Business Mailing Address
First Line	:	670 MASON RIDGE CENTER DR STE 300
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8573
Country	:	US
Telephone Number	:	314-456-7168
Fax Number	:

Provider Business Practice Location Address
First Line	:	1225 GRAHAM RD STE C-1340
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63031-8019
Country	:	US
Telephone Number	:	314-953-6801
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2008
Last Update Date	:	02/28/2021

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