Healthcare Provider Details

I. General information

NPI: 1063973972
Provider Name (Legal Business Name): HENRY CHARLES IDEKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD GARDEN LEVEL, DOOR 3
ST LOUIS MO
63104
US

IV. Provider business mailing address

1008 S SPRING AVE STE 3300
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8884
  • Fax:
Mailing address:
  • Phone: 314-617-3955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMT231592
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License NumberMT231592
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2025029856
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: