Healthcare Provider Details

I. General information

NPI: 1093891228
Provider Name (Legal Business Name): GERALD J LUCHTEFELD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3933 S BROADWAY
SAINT LOUIS MO
63118
US

IV. Provider business mailing address

940 WEST PORT PLAZA STE 270
SAINT LOUIS MO
63146
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-6144
  • Fax:
Mailing address:
  • Phone: 314-453-0600
  • Fax: 314-453-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number077785
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: