Healthcare Provider Details

I. General information

NPI: 1922116763
Provider Name (Legal Business Name): KRISTIN SUZANNE OLIVER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN SUZANNE TATE MD

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 W BROADWAY STE 107
COLUMBIA MO
65203-1317
US

IV. Provider business mailing address

17300 NORTH OUTER 40 RD STE 201
CHESTERFIELD MO
63005-1364
US

V. Phone/Fax

Practice location:
  • Phone: 573-446-4000
  • Fax: 636-778-2828
Mailing address:
  • Phone: 636-778-2900
  • Fax: 636-778-2828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number69818-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number107123
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: