Healthcare Provider Details

I. General information

NPI: 1851541106
Provider Name (Legal Business Name): WEST COUNTY SPINE & SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 NORTH NEW BALLAS RD SUITE 210
ST. LOUIS MO
63141
US

IV. Provider business mailing address

PO BOX 66936
SAINT LOUIS MO
63166-6936
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-4999
  • Fax: 314-432-5088
Mailing address:
  • Phone: 314-432-2580
  • Fax: 314-432-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number113120
License Number StateMO

VIII. Authorized Official

Name: ANTHONY J MARGHERITA
Title or Position: MD
Credential: MD
Phone: 314-432-4999