Healthcare Provider Details

I. General information

NPI: 1457791543
Provider Name (Legal Business Name): CHESTERFIELD PLASTIC & RECONSTRUCTIVE SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SAINT LUKES CENTER DR STE 46B
CHESTERFIELD MO
63017-3509
US

IV. Provider business mailing address

121 SAINT LUKES CENTER DR
CHESTERFIELD MO
63017-3518
US

V. Phone/Fax

Practice location:
  • Phone: 314-205-6420
  • Fax: 314-590-5950
Mailing address:
  • Phone: 636-685-7804
  • Fax: 314-576-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES SNIDER
Title or Position: VP PHYSICIAN NETWORK
Credential:
Phone: 636-685-7804