Healthcare Provider Details

I. General information

NPI: 1548464431
Provider Name (Legal Business Name): GINO JOSEPH VRICELLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 11/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL DIV SURG UROLOGY PED, STE 2A
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

660 S EUCLID AVE MSC 8242-22-02
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6034
  • Fax: 314-454-2876
Mailing address:
  • Phone: 314-362-8200
  • Fax: 314-367-5016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number2013017657
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2013017657
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: