Healthcare Provider Details

I. General information

NPI: 1871058271
Provider Name (Legal Business Name): BROOKE SEMPLE ERWIN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2019
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL DIV IM GASTROENTEROLOGY, STE 12B
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-2066
  • Fax: 314-747-7111
Mailing address:
  • Phone: 314-747-2066
  • Fax: 314-747-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2018009254
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: