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General NPI Number Information
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NPI Number | 1467450023
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Entity Type | Organization
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Legal Business Name | CALDWELL GENERAL PRACTICE, INC.
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Dates
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Enumeration Date | 07/08/2005
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Last Update Date | 05/03/2013
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Provider Practice Location Address
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Address Line | 2880 NETHERTON DR SUITE 103
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City | ST. LOUIS
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State | MO
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Zip | 63136
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Country | US
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Telephone | 314-521-7768
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Fax | 314-838-3683
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Provider Business Mailing Address
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Address Line | 2880 NETHERTON DR SUITE 103
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City | ST. LOUIS
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State | MO
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Zip | 63136
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Country | US
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Telephone | 314-521-7768
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Fax | 314-838-3683
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Authorized Official
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Title or Position | CEO PHYSICIAN
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Name | REYNAL LEON CALDWELL SR.
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Credential | D.O.
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Telephone | 314-521-7768
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | R5E11
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License Number State | MO
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