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General NPI Number Information
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NPI Number | 1649560558
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Entity Type | Organization
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Legal Business Name | ST. LOUIS PEDIATRICS, LLC
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Dates
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Enumeration Date | 04/12/2011
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Last Update Date | 04/12/2011
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Provider Practice Location Address
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Address Line | 8 RAMSGATE DR
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City | OLIVETTE
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State | MO
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Zip | 63132-4116
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Country | US
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Telephone | 314-283-9198
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Fax |
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Provider Business Mailing Address
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Address Line | 3533 DUNN RD STE 210
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City | FLORISSANT
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State | MO
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Zip | 63033-6761
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Country | US
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Telephone | 314-283-9198
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JUSTIN OGBEVOEN
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Credential | M.D
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Telephone | 314-283-9198
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 103771
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License Number State | MO
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