Healthcare Provider Details

I. General information

NPI: 1609839281
Provider Name (Legal Business Name): ROBERT ELROY KRAETSCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MEDICAL PLZ SUITE 100
LAKE ST LOUIS MO
63367-1490
US

IV. Provider business mailing address

500 MEDICAL DR
WENTZVILLE MO
63385-3421
US

V. Phone/Fax

Practice location:
  • Phone: 636-639-8600
  • Fax: 636-639-8666
Mailing address:
  • Phone: 636-327-1202
  • Fax: 363-327-1222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberR6140
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: