Healthcare Provider Details

I. General information

NPI: 1679576359
Provider Name (Legal Business Name): PETER D WEISS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL STE 14B
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

4921 PARKVIEW PL STE 14B
SAINT LOUIS MO
63110-1032
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-5580
  • Fax: 314-454-5583
Mailing address:
  • Phone: 314-454-5580
  • Fax: 314-454-5583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberR6B22
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036083922
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: