Healthcare Provider Details

I. General information

NPI: 1730504119
Provider Name (Legal Business Name): MARY MCDONOUGH SCHILLER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY M MCDONOUGH-SMITH

II. Dates (important events)

Enumeration Date: 02/21/2014
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S WOODS MILL RD STE 140
CHESTERFIELD MO
63017-3427
US

IV. Provider business mailing address

400 S WOODS MILL RD STE 140
CHESTERFIELD MO
63017-3427
US

V. Phone/Fax

Practice location:
  • Phone: 314-485-1104
  • Fax: 314-485-1104
Mailing address:
  • Phone: 314-485-1101
  • Fax: 314-485-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2001016540
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: