=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417015827
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY G GRAVEN D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2006
-----------------------------------------------------
Last Update Date | 11/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 PIPER HILL DR
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-1690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-441-3444
-----------------------------------------------------
Fax | 636-441-9832
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 430
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-0008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-441-3444
-----------------------------------------------------
Fax | 636-441-9832
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | R2F62
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | R2F62
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------