Healthcare Provider Details

I. General information

NPI: 1750143210
Provider Name (Legal Business Name): PODIAPEDICS FOOT SURGERY & WOUND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 BELLEVUE AVE STE 315
SAINT LOUIS MO
63117-1845
US

IV. Provider business mailing address

1035 BELLEVUE AVE STE 315
SAINT LOUIS MO
63117-1845
US

V. Phone/Fax

Practice location:
  • Phone: 314-473-1296
  • Fax: 314-442-7766
Mailing address:
  • Phone: 314-473-1296
  • Fax: 314-442-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: JOHN DERRICK HARNESS
Title or Position: PODIATRIST
Credential: DPM
Phone: 314-473-1296