Healthcare Provider Details

I. General information

NPI: 1356462253
Provider Name (Legal Business Name): SOUTH COUNTY PEDIATRIC ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 LEMAY FERRY RD STE 120
SAINT LOUIS MO
63129
US

IV. Provider business mailing address

4850 LEMAY FERRY RD STE 120
SAINT LOUIS MO
63129-1576
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-3320
  • Fax: 314-849-7766
Mailing address:
  • Phone: 314-849-3320
  • Fax: 314-849-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: IRMA I ORTIZ-ARROYO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 314-849-3320