Healthcare Provider Details

I. General information

NPI: 1417066382
Provider Name (Legal Business Name): ALAN SKOULTCHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 S WOODS MILL RD STE 32W
CHESTERFIELD MO
63017-3442
US

IV. Provider business mailing address

226 S WOODS MILL RD STE 32W
CHESTERFIELD MO
63017-3442
US

V. Phone/Fax

Practice location:
  • Phone: 314-576-1616
  • Fax: 314-576-5271
Mailing address:
  • Phone: 314-576-1616
  • Fax: 314-576-5271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number108583
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: