Healthcare Provider Details

I. General information

NPI: 1700983343
Provider Name (Legal Business Name): REGGIE A VADEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E BROADWAY STE240
COLUMBIA MO
65201-8020
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR STE 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-8145
  • Fax: 573-815-3832
Mailing address:
  • Phone: 573-815-8145
  • Fax: 573-815-3832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberK8545
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number40886
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2014008946
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number2014008945
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: