Healthcare Provider Details

I. General information

NPI: 1881812568
Provider Name (Legal Business Name): ROBERT PHILLIP WALSH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE. AT GRAND BLVD
ST. LOUIS MO
63110
US

IV. Provider business mailing address

300 S GRAND BLVD # 1610
SAINT LOUIS MO
63103-2448
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8750
  • Fax: 314-268-5102
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100021
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: