Healthcare Provider Details

I. General information

NPI: 1689056111
Provider Name (Legal Business Name): JEFFREY EDWARD DESMIDT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2015
Last Update Date: 06/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE ST LOUIS UNIVERSITY HOSPITAL
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

1402 S GRAND BLVD RM M260 ST LOUIS UNIVERSITY SCHOOL OF MEDICINE
SAINT LOUIS MO
63104-1004
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-7133
  • Fax:
Mailing address:
  • Phone: 314-977-9852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2015016412
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: