Healthcare Provider Details

I. General information

NPI: 1952512980
Provider Name (Legal Business Name): LINDSAY FAIRFAX MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10012 KENNERLY RD STE 406
SAINT LOUIS MO
63128-2197
US

IV. Provider business mailing address

10012 KENNERLY RD STE 406
SAINT LOUIS MO
63128-2197
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1224
  • Fax: 314-525-4957
Mailing address:
  • Phone: 314-525-1224
  • Fax: 314-525-4957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301115451
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036140509
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number141098
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01091194A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number70272
License Number StateWI
# 6
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number2022019850
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: