Healthcare Provider Details

I. General information

NPI: 1609405455
Provider Name (Legal Business Name): CHAD AUSTIN STANLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 07/15/2023
Certification Date: 07/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

3959 KEOKUK ST
SAINT LOUIS MO
63116-3511
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-7133
  • Fax:
Mailing address:
  • Phone: 636-634-8189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2023026683
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: