Healthcare Provider Details

I. General information

NPI: 1801415757
Provider Name (Legal Business Name): ZACHARY MICHAEL BARTOCHOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 07/05/2024
Certification Date: 07/05/2024
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: 314-617-2777
  • Fax: 314-768-6625
Mailing address:
  • Phone: 314-617-2777
  • Fax: 314-768-6625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2024012666
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2020017218
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.169089
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: