Healthcare Provider Details

I. General information

NPI: 1386627404
Provider Name (Legal Business Name): NEIL F REBBE MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 11/12/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9553 LACKLAND RD STE 1
SAINT LOUIS MO
63114-3640
US

IV. Provider business mailing address

12255 DEPAUL DRIVE SUITE 300
BRIDGETON MO
63044
US

V. Phone/Fax

Practice location:
  • Phone: 314-429-7733
  • Fax: 314-429-3194
Mailing address:
  • Phone: 314-344-6021
  • Fax: 314-344-6131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number110460
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: