Healthcare Provider Details

I. General information

NPI: 1497395578
Provider Name (Legal Business Name): COLTON SELVIDGE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

PO BOX 22407
SAINT LOUIS MO
63126-0407
US

V. Phone/Fax

Practice location:
  • Phone: 636-386-7222
  • Fax: 636-386-7222
Mailing address:
  • Phone: 636-386-7222
  • Fax: 636-386-7810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN700062
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2021020995
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: