Healthcare Provider Details

I. General information

NPI: 1992713747
Provider Name (Legal Business Name): MARY E GELLENS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 VISTA AVE
SAINT LOUIS MO
63110-2540
US

IV. Provider business mailing address

3691 RUTGER AVE PROVIDER ENROLLMENT
ST LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8765
  • Fax: 314-771-0784
Mailing address:
  • Phone: 314-977-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberR7G08
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: