Provider Demographics
NPI:1356853683
Name:ORTHOPEDIC AND SPINE INSTITUTE OF ST. LOUIS, LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC AND SPINE INSTITUTE OF ST. LOUIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DICKISON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:314-808-3173
Mailing Address - Street 1:10435 CLAYTON RD STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2930
Mailing Address - Country:US
Mailing Address - Phone:314-442-4452
Mailing Address - Fax:866-216-3928
Practice Address - Street 1:10435 CLAYTON RD
Practice Address - Street 2:STE 120
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-442-4452
Practice Address - Fax:866-216-3928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-26
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty