Healthcare Provider Details

I. General information

NPI: 1588675177
Provider Name (Legal Business Name): LAURENCE ARVIN LEVINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11618 GRAVOIS RD
SAINT LOUIS MO
63126-3014
US

IV. Provider business mailing address

11618 GRAVOIS RD
SAINT LOUIS MO
63126-3014
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-1900
  • Fax: 314-842-9185
Mailing address:
  • Phone: 314-842-1900
  • Fax: 314-842-9185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD R4836
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: