Healthcare Provider Details

I. General information

NPI: 1689796294
Provider Name (Legal Business Name): NELSON G USRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11445 OLIVE BLVD
SAINT LOUIS MO
63141-7108
US

IV. Provider business mailing address

11445 OLIVE BLVD
SAINT LOUIS MO
63141-7108
US

V. Phone/Fax

Practice location:
  • Phone: 314-428-9543
  • Fax: 314-428-9542
Mailing address:
  • Phone: 314-428-9543
  • Fax: 314-428-9542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2007018119
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: