Healthcare Provider Details

I. General information

NPI: 1013962133
Provider Name (Legal Business Name): JOHN D RADKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 OAKLAND AVE
SAINT LOUIS MO
63139-3215
US

IV. Provider business mailing address

531 PEBBLE BROOK LN HMAI
BELLEVILLE IL
62221-7609
US

V. Phone/Fax

Practice location:
  • Phone: 314-768-3090
  • Fax: 314-768-3031
Mailing address:
  • Phone: 618-779-5508
  • Fax: 618-206-8588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number28630
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: