Healthcare Provider Details

I. General information

NPI: 1578718375
Provider Name (Legal Business Name): PLASTIC SURGERY CONCEPTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD SUITE 137A
SAINT LOUIS MO
63128-2141
US

IV. Provider business mailing address

11709 OLD BALLAS RD SUITE 201
CREVE COEUR MO
63141-7029
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-8828
  • Fax: 314-432-5105
Mailing address:
  • Phone: 314-997-8828
  • Fax: 314-432-5105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2001004855
License Number StateMO

VIII. Authorized Official

Name: DR. THOMAS V. OLIVIER
Title or Position: OWNER
Credential: MD
Phone: 314-997-8828