Healthcare Provider Details

I. General information

NPI: 1720341092
Provider Name (Legal Business Name): MAIA DORSETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63110-1014
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8072
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-9123
  • Fax: 314-747-3338
Mailing address:
  • Phone: 314-362-9123
  • Fax: 314-747-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2015025967
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number287593
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: