MEDICARE: UROLOGY OF ST. LOUIS, INC.

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	174400000X	Specialist

General Provider Information

NPI Number	:	1407716616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UROLOGY OF ST. LOUIS, INC.

Provider Business Mailing Address
First Line	:	12855 N 40 DR STE 375
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8657
Country	:	US
Telephone Number	:	314-567-6071
Fax Number	:	314-453-9965

Provider Business Practice Location Address
First Line	:	3009 N BALLAS RD STE 250C
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-2323
Country	:	US
Telephone Number	:	314-806-1770
Fax Number	:	314-558-9017

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	ANGIE SMITH
Credential	:
Telephone Number	:	314-336-5062

Provider Enumeration Date	:	11/12/2025
Last Update Date	:	11/12/2025

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