Healthcare Provider Details

I. General information

NPI: 1730716705
Provider Name (Legal Business Name): KERIC LICKERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2500
US

IV. Provider business mailing address

3635 VISTA AVE
SAINT LOUIS MO
63110-2500
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-7133
  • Fax: 314-577-8516
Mailing address:
  • Phone: 314-268-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2023026688
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: