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General NPI Number Information
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NPI Number | 1679699060
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Entity Type | Organization
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Legal Business Name | CHILDREN'S GASTROENTEROLOGY OF ST. LOUIS, P.C.
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Dates
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Enumeration Date | 03/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 224 S WOODS MILL RD STE 640
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City | CHESTERFIELD
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State | MO
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Zip | 63017-3451
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Country | US
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Telephone | 314-576-2080
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Fax | 314-576-0028
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Provider Business Mailing Address
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Address Line | 224 S WOODS MILL RD STE 640
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City | CHESTERFIELD
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State | MO
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Zip | 63017-3451
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Country | US
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Telephone | 314-576-2080
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Fax | 314-576-0028
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JERRY L ROSENBLUM
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Credential | M.D.
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Telephone | 314-576-2080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0206X
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Taxonomy Name | Pediatric Gastroenterology Physician
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License Number |
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License Number State |
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