Healthcare Provider Details

I. General information

NPI: 1518925312
Provider Name (Legal Business Name): HENRY W CLEVER III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S 5TH ST
ST CHARLES MO
63301
US

IV. Provider business mailing address

901 S 5TH ST
ST CHARLES MO
63301
US

V. Phone/Fax

Practice location:
  • Phone: 636-916-1300
  • Fax: 636-916-1561
Mailing address:
  • Phone: 636-916-1300
  • Fax: 636-916-1561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberR4P68
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: