Healthcare Provider Details

I. General information

NPI: 1508494543
Provider Name (Legal Business Name): GWENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 LANDMARK PARKWAY DR STE 201
SAINT LOUIS MO
63127-1665
US

IV. Provider business mailing address

9701 LANDMARK PARKWAY DR STE 201
SAINT LOUIS MO
63127-1665
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-3828
  • Fax: 314-843-3052
Mailing address:
  • Phone: 314-843-3828
  • Fax: 314-843-3052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT HARDEMAN
Title or Position: PHYSICIAN
Credential: MD
Phone: 314-616-1665