Healthcare Provider Details

I. General information

NPI: 1356853683
Provider Name (Legal Business Name): ORTHOPEDIC AND SPINE INSTITUTE OF ST. LOUIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10435 CLAYTON RD STE 120
SAINT LOUIS MO
63131
US

IV. Provider business mailing address

10435 CLAYTON RD STE 120
SAINT LOUIS MO
63131-2930
US

V. Phone/Fax

Practice location:
  • Phone: 314-442-4452
  • Fax: 866-216-3928
Mailing address:
  • Phone: 314-442-4452
  • Fax: 866-216-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE R DICKISON
Title or Position: PRACTICE ADMINISTRATOR
Credential: RN
Phone: 314-808-3173