Healthcare Provider Details

I. General information

NPI: 1326200692
Provider Name (Legal Business Name): NICHOLAS AUSTIN GREINER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15945 CLAYTON RD STE 210
BALLWIN MO
63011-2491
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 368-931-3606
  • Fax: 636-893-1362
Mailing address:
  • Phone: 636-893-1360
  • Fax: 636-893-1362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2011005769
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: