Healthcare Provider Details

I. General information

NPI: 1639252190
Provider Name (Legal Business Name): PHILLIP STEPHAN CUCULICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL DIV IM CARDIOLOGY, STE 8B
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1291
  • Fax: 314-362-4278
Mailing address:
  • Phone: 314-362-1291
  • Fax: 314-362-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number2005018586
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number2005018586
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: