Healthcare Provider Details

I. General information

NPI: 1952436792
Provider Name (Legal Business Name): DIANE M RUP MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 04/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13065 OLD TESSON FERRY RD
SAINT LOUIS MO
63128-3441
US

IV. Provider business mailing address

13065 OLD TESSON FERRY RD
SAINT LOUIS MO
63128-3441
US

V. Phone/Fax

Practice location:
  • Phone: 314-270-3081
  • Fax: 314-270-3084
Mailing address:
  • Phone: 314-270-3081
  • Fax: 341-270-3087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number103826
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: