Healthcare Provider Details

I. General information

NPI: 1962690180
Provider Name (Legal Business Name): JULIE ANN NEIDICH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 FOREST PARK AVE DIV PA, GENOMIC AND MOLECULAR PATHOLOGY, STE 209
SAINT LOUIS MO
63108-2979
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-5641
  • Fax: 314-362-0369
Mailing address:
  • Phone: 314-362-5641
  • Fax: 314-362-0369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License Number2017022702
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: