Healthcare Provider Details

I. General information

NPI: 1710375928
Provider Name (Legal Business Name): WUCA - CLOVERLEAF PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 VETERANS MEMORIAL PKWY STE 104
SAINT PETERS MO
63376-2299
US

IV. Provider business mailing address

PO BOX 7412049
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 636-939-3362
  • Fax:
Mailing address:
  • Phone: 636-939-3362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CATHY EGHIGIAN
Title or Position: SENIOR DIRECTOR MANAGED CARE
Credential:
Phone: 314-273-0770