Healthcare Provider Details

I. General information

NPI: 1679896716
Provider Name (Legal Business Name): MARANATHA HEALTHCARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9231 W FLORISSANT AVE
SAINT LOUIS MO
63136-1422
US

IV. Provider business mailing address

PO BOX 3980
CHESTERFIELD MO
63006-3980
US

V. Phone/Fax

Practice location:
  • Phone: 314-522-1888
  • Fax: 314-522-9674
Mailing address:
  • Phone: 314-522-1888
  • Fax: 314-522-9674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberR7F89
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberR7F89
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberR7F89
License Number StateMO

VIII. Authorized Official

Name: DR. ADELUOLA G LIPEDE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 314-522-1888