MEDICARE: DR. RUSSELL JOHN CHLYSTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	2014042897	MO

General Provider Information

NPI Number	:	1811603996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL JOHN CHLYSTA

Provider Business Mailing Address
First Line	:	12411 BENNETT SPRINGS CT APT L
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3939
Country	:	US
Telephone Number	:	314-265-9240
Fax Number	:

Provider Business Practice Location Address
First Line	:	11115 NEW HALLS FERRY RD STE 105
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63033-7610
Country	:	US
Telephone Number	:	314-921-6200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2023
Last Update Date	:	01/23/2023

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