Healthcare Provider Details

I. General information

NPI: 1154385417
Provider Name (Legal Business Name): KEVIN O EASLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 NORTH FORTY DR SUITE 200
ST LOUIS MO
63141
US

IV. Provider business mailing address

12855 NORTH FORTY DR SUITE 200
ST LOUIS MO
63141
US

V. Phone/Fax

Practice location:
  • Phone: 314-628-1210
  • Fax: 314-628-1220
Mailing address:
  • Phone: 314-628-1210
  • Fax: 314-628-1220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number105787
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: