Healthcare Provider Details

I. General information

NPI: 1194704833
Provider Name (Legal Business Name): SHERWYN JORDAN WAYNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S KIRKWOOD RD SUITE 120
SAINT LOUIS MO
63122-7254
US

IV. Provider business mailing address

800 S HANLEY RD #7D
SAINT LOUIS MO
63105-2687
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-8887
  • Fax: 314-966-3869
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberR2534
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: