Healthcare Provider Details

I. General information

NPI: 1417928078
Provider Name (Legal Business Name): KAREN L WHITESIDE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 04/18/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6526 LANSDOWNE AVE
SAINT LOUIS MO
63109-2654
US

IV. Provider business mailing address

PO BOX 7412045
CHICAGO IL
60674-2045
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-8777
  • Fax: 314-353-8772
Mailing address:
  • Phone: 314-353-8777
  • Fax: 314-353-8772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2002002173
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: