Healthcare Provider Details

I. General information

NPI: 1649433566
Provider Name (Legal Business Name): SARAH JANE TILLING DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 DEER TRACKS TRL STE 110
SAINT LOUIS MO
63131-1839
US

IV. Provider business mailing address

1715 DEER TRACKS TRAIL ROAD STE 110
SAINT LOUIS MO
63131
US

V. Phone/Fax

Practice location:
  • Phone: 314-919-2600
  • Fax: 314-919-2677
Mailing address:
  • Phone: 314-919-2600
  • Fax: 314-919-2677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2011030408
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: