Healthcare Provider Details

I. General information

NPI: 1497944094
Provider Name (Legal Business Name): PARKSIDE SURGERY AND MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6125 CLAYTON AVE SUITE 430
SAINT LOUIS MO
63139-3265
US

IV. Provider business mailing address

6125 CLAYTON AVE SUITE 430
SAINT LOUIS MO
63139-3265
US

V. Phone/Fax

Practice location:
  • Phone: 314-768-3634
  • Fax: 314-768-3638
Mailing address:
  • Phone: 314-768-3634
  • Fax: 314-768-3638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR5845
License Number StateMO

VIII. Authorized Official

Name: JULIAN C MOSLEY JR.
Title or Position: GENERAL SURGEON/OWNER
Credential: M.D.
Phone: 314-768-3634