Healthcare Provider Details

I. General information

NPI: 1043956030
Provider Name (Legal Business Name): ANDREA RAE BARTLETT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1402 S GRAND BLVD
SAINT LOUIS MO
63104-1004
US

V. Phone/Fax

Practice location:
  • Phone: 314-617-3749
  • Fax:
Mailing address:
  • Phone: 314-617-3749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2025024651
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDO.3423
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: