Healthcare Provider Details

I. General information

NPI: 1063790269
Provider Name (Legal Business Name): DZMITRY MATSIUKEVICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 04/17/2025
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL DIV PED CRITICAL CARE MED
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-2527
  • Fax: 314-747-8880
Mailing address:
  • Phone: 314-454-2527
  • Fax: 314-747-8880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019024454
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number2019024454
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number2019024454
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: