Healthcare Provider Details

I. General information

NPI: 1437590437
Provider Name (Legal Business Name): COURTNEY C GRODIE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12349 DE PAUL DR
BRIDGETON MO
63044-2512
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 314-291-7900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2013016467
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: