Healthcare Provider Details

I. General information

NPI: 1619238862
Provider Name (Legal Business Name): KAITLIN A FARRELL M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 S SPRING AVE
SAINT LOUIS MO
63110-2520
US

IV. Provider business mailing address

1008 S SPRING AVENUE SLUCARE DEPARTMENT OF SURGERY
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-3530
  • Fax: 314-977-1630
Mailing address:
  • Phone: 314-977-3530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2018028876
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: