Healthcare Provider Details

I. General information

NPI: 1225367337
Provider Name (Legal Business Name): ST CLAIR ALLERGY-ASTHMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 07/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 ST. CLAIR PLAZA
ST. CLAIR MO
63077
US

IV. Provider business mailing address

13025 PAGADA PKWY
SAINT LOUIS MO
63127-1931
US

V. Phone/Fax

Practice location:
  • Phone: 636-629-6030
  • Fax: 636-629-6030
Mailing address:
  • Phone: 636-629-6030
  • Fax: 636-629-6030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR3G15
License Number StateMO

VIII. Authorized Official

Name: DR. JOHN D. MARCUM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 636-629-6030