Healthcare Provider Details

I. General information

NPI: 1427790823
Provider Name (Legal Business Name): ABIGAIL THERESA GRANT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA ABIGAIL BERGMAN

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 08/16/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 S BROADWAY
SAINT LOUIS MO
63118-4626
US

IV. Provider business mailing address

3930 S BROADWAY
SAINT LOUIS MO
63118-4626
US

V. Phone/Fax

Practice location:
  • Phone: 314-814-8700
  • Fax:
Mailing address:
  • Phone: 314-814-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2025035234
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: