Healthcare Provider Details

I. General information

NPI: 1891822326
Provider Name (Legal Business Name): GYNECOLOGIC & RECONSTRUCTIVE SURGERY, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 2002 B
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD SUITE 2002 B
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6753
  • Fax: 314-251-4492
Mailing address:
  • Phone: 314-251-6753
  • Fax: 314-251-4492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number112659
License Number StateMO

VIII. Authorized Official

Name: DIONYSIOS K VERONIKIS
Title or Position: OWNER
Credential: MD
Phone: 314-251-6753