Healthcare Provider Details

I. General information

NPI: 1902244825
Provider Name (Legal Business Name): GATEWAY PSYCHIATRIC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11710 OLD BALLAS RD SUITE 110
CREVE COEUR MO
63141-7076
US

IV. Provider business mailing address

11710 OLD BALLAS RD SUITE 110
CREVE COEUR MO
63141-7076
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-1958
  • Fax: 314-567-0037
Mailing address:
  • Phone: 314-567-1958
  • Fax: 314-567-0037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number100250
License Number StateMO

VIII. Authorized Official

Name: DR. GORDON ROBINSON
Title or Position: OWNER
Credential: M.D.
Phone: 314-567-1958