Healthcare Provider Details

I. General information

NPI: 1801060108
Provider Name (Legal Business Name): TOTS THRU TEENS PEDIATRICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 DEPAUL DR. SUITE 490
BRIDGETON MO
63044
US

IV. Provider business mailing address

12255 DEPAUL DR. SUITE 490
BRIDGETON MO
63044
US

V. Phone/Fax

Practice location:
  • Phone: 314-291-7766
  • Fax: 314-291-7767
Mailing address:
  • Phone: 314-291-7766
  • Fax: 314-291-7767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR7C02
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR6G08
License Number StateMO

VIII. Authorized Official

Name: DR. ISABEL L ROSENBLOOM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 314-291-7766