Healthcare Provider Details

I. General information

NPI: 1851915516
Provider Name (Legal Business Name): MATTHEW JOHN LOMMEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

510 S KINGSHIGHWAY BLVD DEPARTMENT OF RADIOLOGY
SAINT LOUIS MO
63110-1076
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-7200
  • Fax:
Mailing address:
  • Phone: 314-362-7200
  • Fax: 314-747-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4351047972
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: