Healthcare Provider Details

I. General information

NPI: 1497864185
Provider Name (Legal Business Name): JEROLD JAY KREISMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11477 OLDE CABIN RD STE 200
SAINT LOUIS MO
63141-7076
US

IV. Provider business mailing address

11477 OLDE CABIN RD STE 200
SAINT LOUIS MO
63141-7130
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-5000
  • Fax: 314-567-3110
Mailing address:
  • Phone: 314-567-5000
  • Fax: 314-567-3110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR6606
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: