Healthcare Provider Details

I. General information

NPI: 1992665103
Provider Name (Legal Business Name): UROLOGY OF ST. LOUIS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2025
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR STE 125
SAINT LOUIS MO
63141-8663
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 314-806-1770
  • Fax: 314-558-9017
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