Healthcare Provider Details

I. General information

NPI: 1255539888
Provider Name (Legal Business Name): ST LOUIS CLINICAL PATHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 OFFICE PKWY
SAINT LOUIS MO
63141-7103
US

IV. Provider business mailing address

660 OFFICE PKWY
SAINT LOUIS MO
63141-7103
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-3556
  • Fax: 314-991-0691
Mailing address:
  • Phone: 314-991-3556
  • Fax: 314-991-0691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberR6748
License Number StateMO

VIII. Authorized Official

Name: DR. SCOTT MARTIN
Title or Position: MANAGER
Credential: MD
Phone: 314-991-3556