Healthcare Provider Details

I. General information

NPI: 1275062432
Provider Name (Legal Business Name): TYLER JAMES GOUGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S NEW BALLAS RD STE 510
SAINT LOUIS MO
63141-8726
US

IV. Provider business mailing address

331 HOSPITAL DR STE A
LEBANON MO
65536-9251
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6710
  • Fax: 314-251-6712
Mailing address:
  • Phone: 417-533-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2020020734
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: