Healthcare Provider Details

I. General information

NPI: 1083979280
Provider Name (Legal Business Name): PEDIATRIC CARE FOR KIDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 FOREST PARK AVE SUITE 101A
SAINT LOUIS MO
63108-2885
US

IV. Provider business mailing address

4100 FOREST PARK AVE SUITE 101A
SAINT LOUIS MO
63108-2885
US

V. Phone/Fax

Practice location:
  • Phone: 636-698-8300
  • Fax:
Mailing address:
  • Phone: 636-698-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BLAINE SAYRE
Title or Position: PRESIDENT
Credential: MD
Phone: 636-698-8300