Healthcare Provider Details

I. General information

NPI: 1174575773
Provider Name (Legal Business Name): ROBERT W GARRETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

3635 VISTA AVE DEPT OF RADIOLOGY; ST. LOUIS UNIV HOSP
SAINT LOUIS MO
63110-0250
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 314-268-5783
  • Fax: 314-268-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036.123770
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number49759
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2010009161
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: