Healthcare Provider Details

I. General information

NPI: 1619355765
Provider Name (Legal Business Name): BENJAMIN ZIMMERMAN ROOT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2015
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11525 OLDE CABIN RD
SAINT LOUIS MO
63141-7146
US

IV. Provider business mailing address

11525 OLDE CABIN RD
SAINT LOUIS MO
63141-7146
US

V. Phone/Fax

Practice location:
  • Phone: 314-279-9049
  • Fax: 314-997-5086
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2021008458
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: