Healthcare Provider Details

I. General information

NPI: 1336440593
Provider Name (Legal Business Name): ST LOUIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

3545 LINDELL BLVD FL 3
SAINT LOUIS MO
63103-1020
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-4101
  • Fax: 314-577-5379
Mailing address:
  • Phone: 314-977-6828
  • Fax: 314-977-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: ALYCE LANXON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-977-6828