Healthcare Provider Details

I. General information

NPI: 1114380052
Provider Name (Legal Business Name): CENTRAL WEST END ENDOSCOPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 02/23/2025
Certification Date: 02/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 DELMAR BLVD STE B
ST. LOUIS MO
63108-1702
US

IV. Provider business mailing address

4510 DELMAR BLVD STE B
ST. LOUIS MO
63108-1702
US

V. Phone/Fax

Practice location:
  • Phone: 314-334-4499
  • Fax: 314-696-0073
Mailing address:
  • Phone: 314-334-4499
  • Fax: 314-696-0073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
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: DAVID RUSSELL HORACE
Title or Position: CONSULTANT
Credential:
Phone: 618-235-2299