=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609263409
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON THOMAS RICCIUTI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2015
-----------------------------------------------------
Last Update Date | 11/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6420 CLAYTON RD STE 290
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63117-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-977-7455
-----------------------------------------------------
Fax | 314-977-7477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6420 CLAYTON RD STE 290
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63117-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-977-7455
-----------------------------------------------------
Fax | 314-977-7477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VX0201X
-----------------------------------------------------
Taxonomy Name | Gynecologic Oncology Physician
-----------------------------------------------------
License Number | 2022034017
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------