Healthcare Provider Details

I. General information

NPI: 1033130588
Provider Name (Legal Business Name): JAY NOFFSINGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

3691 RUTGER ST PROVIDER ENROLLMENT
SAINT LOUIS MO
63110-2515
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5369
  • Fax: 314-577-5379
Mailing address:
  • Phone: 314-977-6828
  • Fax: 314-977-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberR2J74
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR2J74
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberR2J74
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: