Healthcare Provider Details

I. General information

NPI: 1679876734
Provider Name (Legal Business Name): ST. JOHN'S PEDIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 12/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD # 2003B
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD # 2003B,
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6299
  • Fax:
Mailing address:
  • Phone: 314-251-6299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number2010034857
License Number StateMO

VIII. Authorized Official

Name: DR. JOESPH KAHN
Title or Position: DEPARTMENT CHAIRMAN/SUPERVISOR
Credential: MD
Phone: 314-251-6299