Healthcare Provider Details

I. General information

NPI: 1144339334
Provider Name (Legal Business Name): ATHLETICS SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7508 BIG BEND BLVD
SAINT LOUIS MO
63119-2104
US

IV. Provider business mailing address

7508 BIG BEND BLVD
SAINT LOUIS MO
63119-2104
US

V. Phone/Fax

Practice location:
  • Phone: 314-341-4931
  • Fax: 314-647-1964
Mailing address:
  • Phone: 314-341-4931
  • Fax: 314-647-1964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number1999135803
License Number StateMO

VIII. Authorized Official

Name: DR. CYD CHARISSE WILLIAMS
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 314-647-4880