Healthcare Provider Details

I. General information

NPI: 1942392931
Provider Name (Legal Business Name): WILLIAM M IRVIN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11477 OLDE CABIN RD STE 210
SAINT LOUIS MO
63141-7129
US

IV. Provider business mailing address

11477 OLDE CABIN RD STE 210
CREVE COEUR MO
63141-7129
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-5208
  • Fax: 314-997-5368
Mailing address:
  • Phone: 314-997-5208
  • Fax: 314-997-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number2001010868
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: