Healthcare Provider Details

I. General information

NPI: 1952775751
Provider Name (Legal Business Name): MIDWEST UROGYNECOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 DOUGHERTY FERRY RD STE 206
SAINT LOUIS MO
63122-3356
US

IV. Provider business mailing address

2325 DOUGHERTY FERRY RD STE 206
SAINT LOUIS MO
63122-3356
US

V. Phone/Fax

Practice location:
  • Phone: 314-596-9955
  • Fax: 314-596-9530
Mailing address:
  • Phone: 314-596-9955
  • Fax: 314-596-9530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2011012595
License Number StateMO

VIII. Authorized Official

Name: JOHN JUDD
Title or Position: OWNER
Credential: MD
Phone: 314-596-9955