Healthcare Provider Details

I. General information

NPI: 1265794911
Provider Name (Legal Business Name): REGENERATION ORTHOPEDICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 MCBRIDE & SON CENTER DR. STE 204
CHESTERFIELD MO
63005
US

IV. Provider business mailing address

14825 N OUTER 40 RD STE 365
CHESTERFIELD MO
63017-2152
US

V. Phone/Fax

Practice location:
  • Phone: 636-536-7000
  • Fax: 636-898-5709
Mailing address:
  • Phone: 636-536-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN O. WILSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 636-536-7000