Healthcare Provider Details

I. General information

NPI: 1396217394
Provider Name (Legal Business Name): CARL D. SUMMERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 OLIVE ST
SAINT LOUIS MO
63103-2360
US

IV. Provider business mailing address

1430 OLIVE ST
SAINT LOUIS MO
63103-2360
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3700
  • Fax:
Mailing address:
  • Phone: 314-206-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: