=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467530410
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENRY PURCELL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 09/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6812 STATE ROUTE 162 STE 121
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62062-8586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-391-6910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 797021
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63179-7000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-644-3535
-----------------------------------------------------
Fax | 314-644-3255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | R9H62
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------