Healthcare Provider Details

I. General information

NPI: 1043305428
Provider Name (Legal Business Name): ST. GERARD OBSTETRICS AND GYNECOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY ROAD SUITE 386B
ST. LOUIS MO
63128
US

IV. Provider business mailing address

10004 KENNERLY ROAD SUITE 386B
ST. LOUIS MO
63128
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-7910
  • Fax: 314-842-7911
Mailing address:
  • Phone: 314-842-7910
  • Fax: 314-842-7911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MICHAEL B DIXON
Title or Position: OWNER
Credential: M.D.
Phone: 314-842-7910