Healthcare Provider Details

I. General information

NPI: 1679919005
Provider Name (Legal Business Name): DR. KRISTINA WILSON MCCORMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 CLAYTON RD DEPT. OF OB/GYN
SAINT LOUIS MO
63117-1811
US

IV. Provider business mailing address

6420 CLAYTON RD DEPT. OF OB/GYN
SAINT LOUIS MO
63117-1811
US

V. Phone/Fax

Practice location:
  • Phone: 314-768-8800
  • Fax: 314-645-8771
Mailing address:
  • Phone: 314-768-8800
  • Fax: 314-645-8771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2013021769
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: