=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073927026
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GALEN NELSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2014
-----------------------------------------------------
Last Update Date | 03/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 S GRAND BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63104-1016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-257-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3691 RUTGER ST DEPT OF
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63110-2515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-977-5700
-----------------------------------------------------
Fax | 314-977-1617
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 7233
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------