Healthcare Provider Details

I. General information

NPI: 1528017191
Provider Name (Legal Business Name): UROLOGY OF ST. LOUIS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR STE 375
SAINT LOUIS MO
63141-8657
US

IV. Provider business mailing address

PO BOX 14369
SAINT LOUIS MO
63178-4369
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-6071
  • Fax: 314-453-9965
Mailing address:
  • Phone: 314-567-6071
  • Fax: 314-453-9965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ANGIE SMITH
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 314-336-5062