Healthcare Provider Details

I. General information

NPI: 1407490105
Provider Name (Legal Business Name): EAR NOSE THROAT MEDICAL SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 S WOODS MILL RD STE 44W
CHESTERFIELD MO
63017-3442
US

IV. Provider business mailing address

1324 CLARKSON CLAYTON CTR STE 301
ELLISVILLE MO
63011-2145
US

V. Phone/Fax

Practice location:
  • Phone: 314-447-4995
  • Fax: 314-682-6093
Mailing address:
  • Phone: 314-541-6838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN BURK
Title or Position: DESIGNATED OFFICIAL
Credential:
Phone: 314-541-6838