Healthcare Provider Details

I. General information

NPI: 1578509337
Provider Name (Legal Business Name): MARK D RICKMEYER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 GRAVOIS RD STE 210
FENTON MO
63026-7723
US

IV. Provider business mailing address

714 GRAVOIS RD STE 210
FENTON MO
63026-7723
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5230
  • Fax: 314-543-5280
Mailing address:
  • Phone: 636-660-9850
  • Fax: 636-660-9851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number106510
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: