Healthcare Provider Details

I. General information

NPI: 1083693790
Provider Name (Legal Business Name): ANDREW MICHAEL WAYNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N NEW BALLAS RD STE 175
SAINT LOUIS MO
63141-6884
US

IV. Provider business mailing address

PO BOX 843857
KANSAS CITY MO
64184-3857
US

V. Phone/Fax

Practice location:
  • Phone: 314-786-2663
  • Fax: 314-279-1037
Mailing address:
  • Phone: 314-966-8887
  • Fax: 314-317-1398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number106770
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: