Healthcare Provider Details

I. General information

NPI: 1376583070
Provider Name (Legal Business Name): TREVOR L TREDWAY MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5360
  • Fax: 314-268-4116
Mailing address:
  • Phone: 314-577-5360
  • Fax: 314-268-4116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2003006429
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: