Healthcare Provider Details

I. General information

NPI: 1467824649
Provider Name (Legal Business Name): PRO PHYSICIANS CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 10/27/2015
Certification Date:
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

PO BOX 678234
DALLAS TX
75267-8234
US

V. Phone/Fax

Practice location:
  • Phone: 314-665-3096
  • Fax:
Mailing address:
  • Phone: 512-583-0205
  • Fax:

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: JON TRYGGESTAD
Title or Position: CEO
Credential:
Phone: 972-573-4611