Healthcare Provider Details

I. General information

NPI: 1427004829
Provider Name (Legal Business Name): ROBERT C CORLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY ATTN: CREDENTIALING
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 314-289-6410
  • Fax:
Mailing address:
  • Phone: 314-989-0300
  • Fax: 314-810-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2004005138
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: