Healthcare Provider Details

I. General information

NPI: 1003883430
Provider Name (Legal Business Name): KATHRYN BOTNEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 08/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 4005
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

4 WOODCLIFFE RD
SAINT LOUIS MO
63124-1337
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-5016
  • Fax: 314-567-1846
Mailing address:
  • Phone: 314-692-2788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberR2G88
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: