Healthcare Provider Details

I. General information

NPI: 1720064009
Provider Name (Legal Business Name): OTHA RAY RAINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date: 12/21/2005
Reactivation Date: 01/12/2006

III. Provider practice location address

11123 S TOWNE SQ SUITE E
SAINT LOUIS MO
63123-7816
US

IV. Provider business mailing address

4 HAVEN VIEW DR
CREVE COEUR MO
63141-7902
US

V. Phone/Fax

Practice location:
  • Phone: 314-487-4537
  • Fax:
Mailing address:
  • Phone: 314-603-3794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-066358
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR3G19
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: