Healthcare Provider Details

I. General information

NPI: 1760656607
Provider Name (Legal Business Name): JUDITH GURLEY PLASTIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14825 N OUTER 40 #350
CHESTERFIELD MO
63017-2152
US

IV. Provider business mailing address

14825 N OUTER 40 #350
CHESTERFIELD MO
63017-2152
US

V. Phone/Fax

Practice location:
  • Phone: 636-812-4300
  • Fax: 636-812-4307
Mailing address:
  • Phone: 636-812-4300
  • Fax: 636-812-4307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number114740
License Number StateMO

VIII. Authorized Official

Name: DR. JUDITH MORIN GURLEY
Title or Position: SURGEON/MEMBER
Credential: M.D.
Phone: 636-812-4300