Healthcare Provider Details

I. General information

NPI: 1578758470
Provider Name (Legal Business Name): EUREKA PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N VIRGINIA AVE
EUREKA MO
63025-1115
US

IV. Provider business mailing address

515 N VIRGINIA AVE
EUREKA MO
63025-1115
US

V. Phone/Fax

Practice location:
  • Phone: 636-587-3000
  • Fax: 636-587-2243
Mailing address:
  • Phone: 636-587-3000
  • Fax: 636-587-2243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TED ALLEN GREEN
Title or Position: OWNER
Credential: M.D.
Phone: 636-587-3000