Healthcare Provider Details

I. General information

NPI: 1891049979
Provider Name (Legal Business Name): REGENERATION ORTHOPEDICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12348 OLD TESSON RD STE120
SAINT LOUIS MO
63128-2251
US

IV. Provider business mailing address

6 MCBRIDE AND SON CENTER DR STE 204
CHESTERFIELD MO
63005-1418
US

V. Phone/Fax

Practice location:
  • Phone: 636-536-7000
  • Fax: 636-898-5709
Mailing address:
  • Phone: 636-536-7000
  • Fax: 636-898-5709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN WILSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 636-536-7000