Healthcare Provider Details

I. General information

NPI: 1932170859
Provider Name (Legal Business Name): ERIC SUTPHEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 01/16/2015
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

215 DUNN RD
FLORISSANT MO
63031-7928
US

V. Phone/Fax

Practice location:
  • Phone: 314-227-2301
  • Fax: 314-227-2316
Mailing address:
  • Phone: 314-315-9913
  • Fax: 314-872-8069

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:
Title or Position:
Credential:
Phone: