Healthcare Provider Details

I. General information

NPI: 1982153268
Provider Name (Legal Business Name): DAVIS A SPIELBAUER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 11/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S KINGSHIGHWAY BLVD DEPT EMERGENCY MEDICINE
SAINT LOUIS MO
63110-1014
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8072
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-9123
  • Fax: 314-747-3338
Mailing address:
  • Phone: 314-362-9123
  • Fax: 314-747-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2018034230
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: