Healthcare Provider Details

I. General information

NPI: 1174753982
Provider Name (Legal Business Name): HARRY GUS GREDITZER IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7733 FORSYTH BLVD
SAINT LOUIS MO
63105-1817
US

IV. Provider business mailing address

535 E 70TH ST
NEW YORK NY
10021-4823
US

V. Phone/Fax

Practice location:
  • Phone: 212-606-1015
  • Fax:
Mailing address:
  • Phone: 212-606-1015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2009020446
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2015043933
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME112133
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number274799
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: