Healthcare Provider Details

I. General information

NPI: 1033773684
Provider Name (Legal Business Name): OLUWABAMISE RAYMOND AKINNAWO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVENUE EMERGENCY MEDICINE ADMINISTRATION - 1ST FLOOR(FDT)
ST. LOUIS MO
63110
US

IV. Provider business mailing address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8780
  • Fax:
Mailing address:
  • Phone: 314-577-8780
  • Fax: 314-577-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2021035901
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number92376
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: