Healthcare Provider Details

I. General information

NPI: 1659477024
Provider Name (Legal Business Name): EDEN PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 S NEW BALLAS RD SUITE 220
SAINT LOUIS MO
63141-8704
US

IV. Provider business mailing address

763 S NEW BALLAS RD STE 220
SAINT LOUIS MO
63141-8711
US

V. Phone/Fax

Practice location:
  • Phone: 314-983-0606
  • Fax: 314-983-0608
Mailing address:
  • Phone: 314-983-0606
  • Fax: 314-983-0608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD101423
License Number StateMO

VIII. Authorized Official

Name: DR. ETIHAD SHAKIR AL-FALAHI
Title or Position: PRESIDENT
Credential: M.D
Phone: 314-983-0606