Healthcare Provider Details

I. General information

NPI: 1154714202
Provider Name (Legal Business Name): HEIDI ELAINE ROEDER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 3005B
SAINT LOUIS MO
63141-8266
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 3005B
SAINT LOUIS MO
63141-8266
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-7070
  • Fax: 314-251-7071
Mailing address:
  • Phone: 314-251-7070
  • Fax: 314-251-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2015006471
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: