Healthcare Provider Details

I. General information

NPI: 1295900645
Provider Name (Legal Business Name): GREG LODYGENSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

CAMPUS BOX 8221 7425 FORSYTH
SAINT LOUIS MO
63105-2161
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6148
  • Fax: 314-454-4633
Mailing address:
  • Phone: 314-935-0770
  • Fax: 314-935-0575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2005018543
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number2005018543
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: