Healthcare Provider Details

I. General information

NPI: 1770501660
Provider Name (Legal Business Name): GINA MARUSIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 SUNSET OFFICE DR SUITE 101
SAINT LOUIS MO
63127-1015
US

IV. Provider business mailing address

3555 SUNSET OFFICE DR SUITE 101
SAINT LOUIS MO
63127-1015
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-3324
  • Fax: 314-966-6327
Mailing address:
  • Phone: 314-822-5900
  • Fax: 314-822-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMO100990
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: