Healthcare Provider Details

I. General information

NPI: 1871115857
Provider Name (Legal Business Name): BEN HEIMOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S COMPTON AVE
SAINT LOUIS MO
63103-2001
US

IV. Provider business mailing address

1 S COMPTON AVE
SAINT LOUIS MO
63103-2001
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-7018
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2017007317
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: