Healthcare Provider Details

I. General information

NPI: 1902113301
Provider Name (Legal Business Name): BIRGIT STERZL DIETICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BOND AVE
CENTREVILLE IL
62207-2326
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY CREDENTIALING DEPARTMENT
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 618-332-5212
  • Fax:
Mailing address:
  • Phone: 314-872-1308
  • Fax: 314-810-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164003710
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: