Healthcare Provider Details

I. General information

NPI: 1144291659
Provider Name (Legal Business Name): E. SUTPHEN MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1688
  • Fax: 314-525-1689
Mailing address:
  • Phone: 314-525-1688
  • Fax: 314-525-1689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberR2P24
License Number StateMO

VIII. Authorized Official

Name: DR. ERIC SUTPHEN
Title or Position: DELEGATED OFFICIAL
Credential: MD
Phone: 314-525-1688