Healthcare Provider Details

I. General information

NPI: 1477246312
Provider Name (Legal Business Name): ST. LOUIS VASCULAR SURGICAL SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 HRC PLAZA DR
LAKE ST LOUIS MO
63367-2360
US

IV. Provider business mailing address

1901 HRC PLAZA DR
LAKE ST LOUIS MO
63367-2360
US

V. Phone/Fax

Practice location:
  • Phone: 314-755-1084
  • Fax: 314-755-1184
Mailing address:
  • Phone: 314-755-1084
  • Fax: 314-755-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT IVAN HACKER
Title or Position: CEO OWNER
Credential: MD
Phone: 314-755-1084