Healthcare Provider Details

I. General information

NPI: 1649639212
Provider Name (Legal Business Name): AMY GLUECK RD, CSO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ MAILSTOP 90-17-334
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

1 BARNES JEWISH HOSPITAL PLZ MAILSTOP 90-17-334
SAINT LOUIS MO
63110-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-7619
  • Fax: 314-362-7769
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2012026835
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: