Healthcare Provider Details

I. General information

NPI: 1811082530
Provider Name (Legal Business Name): LAURIE E. BYRNE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE WEST PAVILION, ROOM 315
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

3691 RUTGER ST PROVIDER ENROLLMENT
SAINT LOUIS MO
63110-2515
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8776
  • Fax: 314-268-5697
Mailing address:
  • Phone: 314-977-6828
  • Fax: 314-977-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number115981
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: