Healthcare Provider Details

I. General information

NPI: 1730106725
Provider Name (Legal Business Name): STL PLASTIC AND HAND SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR NORTH TOWER SUITE 380
SAINT LOUIS MO
63141-8657
US

IV. Provider business mailing address

12855 N 40 DR NORTH TOWER SUITE 380
SAINT LOUIS MO
63141-8657
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-7784
  • Fax:
Mailing address:
  • Phone: 314-434-3603
  • Fax: 314-434-3603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2002014802
License Number StateMO

VIII. Authorized Official

Name: DR. ROBERT HAGAN
Title or Position: MANAGING EMPLOYEE/OWNER
Credential: MD
Phone: 314-434-7784