Healthcare Provider Details

I. General information

NPI: 1306120183
Provider Name (Legal Business Name): ST LOUIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 SOUTH GRAND 2L, DOOR 5
ST LOUIS MO
63104-6310
US

IV. Provider business mailing address

3545 LINDELL BLVD FL 3
SAINT LOUIS MO
63103-1020
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4440
  • Fax:
Mailing address:
  • Phone: 314-977-6828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALYCE LANXON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-977-6828