Healthcare Provider Details

I. General information

NPI: 1568499846
Provider Name (Legal Business Name): S VIC GLOGOVAC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 DE PAUL DR SUITE 165
BRIDGETON MO
63044-2510
US

IV. Provider business mailing address

12255 DE PAUL DR SUITE 165
BRIDGETON MO
63044-2510
US

V. Phone/Fax

Practice location:
  • Phone: 314-291-7510
  • Fax: 314-291-0001
Mailing address:
  • Phone: 314-291-7510
  • Fax: 314-291-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License NumberR9513
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: