=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154418424
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALD W MORITZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2006
-----------------------------------------------------
Last Update Date | 11/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11125 DUNN RD STE 201
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63136-6132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-362-7509
-----------------------------------------------------
Fax | 314-362-7522
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 660 S EUCLID AVE CB 8115
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63110-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-362-7509
-----------------------------------------------------
Fax | 314-362-7522
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 32656
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------