Healthcare Provider Details

I. General information

NPI: 1023029121
Provider Name (Legal Business Name): ST LOUIS GYNECOLOGY & ONCOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11652 STUDT AVE
SAINT LOUIS MO
63141-7025
US

IV. Provider business mailing address

11652 STUDT AVE
SAINT LOUIS MO
63141-7025
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-5445
  • Fax: 314-991-5447
Mailing address:
  • Phone: 314-991-5445
  • Fax: 314-991-5447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number110171
License Number StateMO

VIII. Authorized Official

Name: ALAA A ELBENDARY
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 314-991-5445