Healthcare Provider Details

I. General information

NPI: 1073505178
Provider Name (Legal Business Name): MICHAEL J ZEREGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BREVCO PLZ SUITE 208
LAKE ST LOUIS MO
63367-2949
US

IV. Provider business mailing address

200 BREVCO PLZ SUITE 208
LAKE ST LOUIS MO
63367-2949
US

V. Phone/Fax

Practice location:
  • Phone: 636-561-9020
  • Fax: 636-561-6208
Mailing address:
  • Phone: 636-561-9020
  • Fax: 636-561-6208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2000154596
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: