Healthcare Provider Details

I. General information

NPI: 1578613915
Provider Name (Legal Business Name): CATHERINE ELIZABETH ROANE-BLAKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11125 DUNN RD STE 406
SAINT LOUIS MO
63136
US

IV. Provider business mailing address

11125 DUNN RD STE 406
SAINT LOUIS MO
63136-6132
US

V. Phone/Fax

Practice location:
  • Phone: 314-653-5484
  • Fax: 314-653-5483
Mailing address:
  • Phone: 314-653-5484
  • Fax: 314-653-5483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number2018010680
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberG5543
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2018010680
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: