Healthcare Provider Details

I. General information

NPI: 1417189564
Provider Name (Legal Business Name): AMY LODEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 N BALLAS RD STE 440
SAINT LOUIS MO
63131
US

IV. Provider business mailing address

3023 N BALLAS RD, BUILDING D SUITE 440
SAINT LOUIS MO
63131-2363
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-8181
  • Fax:
Mailing address:
  • Phone: 314-432-8181
  • Fax: 314-432-0090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2013018497
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: