Healthcare Provider Details

I. General information

NPI: 1750896635
Provider Name (Legal Business Name): STL SURGICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12184 NATURAL BRIDGE RD
BRIDGETON MO
63044-2017
US

IV. Provider business mailing address

5203 CHIPPEWA ST STE 301
SAINT LOUIS MO
63109-2356
US

V. Phone/Fax

Practice location:
  • Phone: 314-481-3037
  • Fax:
Mailing address:
  • Phone: 314-481-5000
  • Fax: 314-481-3037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTEN BRANNON
Title or Position: ADMINISTRATOR
Credential: ADMINISTRATOR
Phone: 502-303-0919