Healthcare Provider Details

I. General information

NPI: 1215902648
Provider Name (Legal Business Name): LYNDON BERNARD GROSS M.D., PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 06/06/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11330 OLIVE BLVD SUITE 150
CREVE COEUR MO
63141
US

IV. Provider business mailing address

11330 OLIVE BLVD SUITE 150
CREVE COEUR MO
63141
US

V. Phone/Fax

Practice location:
  • Phone: 314-336-2566
  • Fax: 314-948-9011
Mailing address:
  • Phone: 314-336-2566
  • Fax: 314-948-9011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number119343
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: