=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629105259
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. LOUIS EYE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 06/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12818 TESSON FERRY RD STE 102&104
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-352-9800
-----------------------------------------------------
Fax | 314-352-4290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12818 TESSON FERRY RD STE 102&104
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-352-9800
-----------------------------------------------------
Fax | 314-352-4290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING & BILLING SPECIALIST
-----------------------------------------------------
Name | ELIZABETH DEBORAH KUTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-352-9800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0009X
-----------------------------------------------------
Taxonomy Name | Glaucoma Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------