Healthcare Provider Details

I. General information

NPI: 1881668564
Provider Name (Legal Business Name): STEVEN MARK ABBADESSA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 N NEW BALLAS RD STE 154
SAINT LOUIS MO
63141-6827
US

IV. Provider business mailing address

456 N NEW BALLAS RD STE 154
SAINT LOUIS MO
63141-6827
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-7570
  • Fax: 314-966-7788
Mailing address:
  • Phone: 314-966-7570
  • Fax: 314-966-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberR5J14
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: