Healthcare Provider Details

I. General information

NPI: 1780024109
Provider Name (Legal Business Name): TEDDY MWIMI MUISYO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2013
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S EUCLID AVE
SAINT LOUIS MO
63110-1010
US

IV. Provider business mailing address

660 S EUCLID AVE CAMPUS BOX 8116
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-2224
  • Fax:
Mailing address:
  • Phone: 314-286-2224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125062844
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberU2273
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2016023348
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: