Provider Demographics
NPI:1235461906
Name:STEPHANIE KROGH OD LLC
Entity Type:Organization
Organization Name:STEPHANIE KROGH OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:314-968-6432
Mailing Address - Street 1:100 THF BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1123
Mailing Address - Country:US
Mailing Address - Phone:636-536-4609
Mailing Address - Fax:
Practice Address - Street 1:2440 ANNALEE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2210
Practice Address - Country:US
Practice Address - Phone:314-968-6432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000091325Medicare PIN
MOU02619Medicare UPIN