Healthcare Provider Details

I. General information

NPI: 1174366546
Provider Name (Legal Business Name): JOSHUA ISHMAEL MEMBRENO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEW HOSP PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

660 S EUCLID AVE, MAIL STOP 8121-0022-07
ST LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-8065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2024018212
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: