Healthcare Provider Details

I. General information

NPI: 1619498557
Provider Name (Legal Business Name): NOAM GRYSMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1438 S GRAND BLVD
SAINT LOUIS MO
63104-1027
US

IV. Provider business mailing address

1438 S GRAND BLVD
SAINT LOUIS MO
63104-1027
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4828
  • Fax: 314-977-4876
Mailing address:
  • Phone: 314-617-2777
  • Fax: 314-617-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2020031778
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD22897
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number2020031778
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: