Healthcare Provider Details

I. General information

NPI: 1205578754
Provider Name (Legal Business Name): ADVANCED ANORECTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12401 OLIVE BLVD STE 202
CREVE COEUR MO
63141-5448
US

IV. Provider business mailing address

12401 OLIVE BLVD STE 202
SAINT LOUIS MO
63141-5448
US

V. Phone/Fax

Practice location:
  • Phone: 314-834-2888
  • Fax: 314-834-5212
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: HANNAH-NGOC T HA
Title or Position: OWNER/ MD
Credential:
Phone: 314-249-0789