Healthcare Provider Details

I. General information

NPI: 1558387019
Provider Name (Legal Business Name): RUSSELL W PICKETT AU.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10900 MANCHESTER RD SUITE #202
KIRKWOOD MO
63122-1200
US

IV. Provider business mailing address

10900 MANCHESTER RD SUITE #202
KIRKWOOD MO
63122-1200
US

V. Phone/Fax

Practice location:
  • Phone: 314-835-9996
  • Fax: 314-835-9992
Mailing address:
  • Phone: 314-835-9996
  • Fax: 314-835-9992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number110299
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: