Healthcare Provider Details

I. General information

NPI: 1265044804
Provider Name (Legal Business Name): GENESISCARE LANDMARK MISSOURI CANCER CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N NEW BALLAS RD STE 70W
SAINT LOUIS MO
63141-6833
US

IV. Provider business mailing address

2160 COLONIAL BLVD
FORT MYERS FL
33907-1410
US

V. Phone/Fax

Practice location:
  • Phone: 314-665-3096
  • Fax:
Mailing address:
  • Phone: 239-931-7342
  • Fax: 239-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY T. TRIPLETTE
Title or Position: PRESIDENT
Credential: MD
Phone: 314-665-3096