Healthcare Provider Details

I. General information

NPI: 1508975160
Provider Name (Legal Business Name): ELAINE C SIEGFRIED MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-3450
  • Fax: 314-268-4077
Mailing address:
  • Phone: 314-577-3450
  • Fax: 314-268-4077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number101877
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: