Healthcare Provider Details

I. General information

NPI: 1871762385
Provider Name (Legal Business Name): DOCTOR'S CLINICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 DEPAUL DRIVE SUITE 865
BRIDGETON MO
63044
US

IV. Provider business mailing address

PO BOX 790379
SAINT LOUIS MO
63179-0379
US

V. Phone/Fax

Practice location:
  • Phone: 314-291-0505
  • Fax: 314-291-0747
Mailing address:
  • Phone: 314-291-0505
  • Fax: 314-291-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29351
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number152467
License Number StateMO

VIII. Authorized Official

Name: ROBERT P. POETZ
Title or Position: OWNER
Credential: D.O.
Phone: 314-291-0505