Healthcare Provider Details

I. General information

NPI: 1730610155
Provider Name (Legal Business Name): JOSE EMILIO MORALES MORENO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD RM 2717 SSM HEALTH CARDINAL GLENNON CHILDREN'S HOSPITAL
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD RM 2717 SSM HEALTH CARDINAL GLENNON CHILDREN'S HOSPITAL
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5634
  • Fax: 314-577-5616
Mailing address:
  • Phone: 314-577-5634
  • Fax: 314-577-5616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number11705342-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: