Healthcare Provider Details

I. General information

NPI: 1366543746
Provider Name (Legal Business Name): ANDREW T PICKENS III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD SUITE 500
ST LOUIS MO
63117
US

IV. Provider business mailing address

1034 S BRENTWOOD BLVD SUITE 500
ST LOUIS MO
63117
US

V. Phone/Fax

Practice location:
  • Phone: 314-727-2700
  • Fax: 314-727-2773
Mailing address:
  • Phone: 314-727-2700
  • Fax: 314-727-2773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number32150
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: