MEDICARE: LUIS J ANGLO 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	208800000X	Urology Physician	R1P44	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00195679	OTHER	MO	PALMETTO RR MEDIARE

General Provider Information

NPI Number	:	1437112547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS J ANGLO M.D.

Provider Business Mailing Address
First Line	:	701 S NEW BALLAS RD STE 330
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8702
Country	:	US
Telephone Number	:	314-251-8850
Fax Number	:	314-569-3846

Provider Business Practice Location Address
First Line	:	701 S NEW BALLAS RD STE 330
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8702
Country	:	US
Telephone Number	:	314-251-8850
Fax Number	:	314-569-3846

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

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	09/06/2023

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