Healthcare Provider Details

I. General information

NPI: 1679520605
Provider Name (Legal Business Name): SEAN LEWIS EDELSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 01/19/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-5200
  • Fax: 314-977-9910
Mailing address:
  • Phone: 314-977-4010
  • Fax: 314-977-3495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2005019369
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2005019369
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2005019369
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: