MEDICARE: ST LOUIS UNIVERSITY

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

General Provider Information

NPI Number	:	1487627717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST LOUIS UNIVERSITY

Provider Business Mailing Address
First Line	:	3545 LINDELL BLVD FL 3
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-1020
Country	:	US
Telephone Number	:	314-977-6828
Fax Number	:	314-977-6872

Provider Business Practice Location Address
First Line	:	2315 DOUGHERTY FERRY RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-3383
Country	:	US
Telephone Number	:	314-977-6828
Fax Number	:	314-977-5268

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. ALYCE LANXON
Credential	:
Telephone Number	:	314-977-6828

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	09/21/2021

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Directions to “ST LOUIS UNIVERSITY ” Practice Location

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