Healthcare Provider Details

I. General information

NPI: 1114675147
Provider Name (Legal Business Name): SHERYL BRYAN LYSS MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD STE 1120
SAINT LOUIS MO
63117-1211
US

IV. Provider business mailing address

1034 S BRENTWOOD BLVD STE 1120
SAINT LOUIS MO
63117-1211
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8491
  • Fax:
Mailing address:
  • Phone: 314-617-3000
  • Fax: 314-726-1653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number2022013899
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number2022013899
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: