Provider Demographics
NPI:1659477024
Name:EDEN PEDIATRICS LLC
Entity Type:Organization
Organization Name:EDEN PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ETIHAD
Authorized Official - Middle Name:SHAKIR
Authorized Official - Last Name:AL-FALAHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-983-0606
Mailing Address - Street 1:763 S NEW BALLAS RD STE 220
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8711
Mailing Address - Country:US
Mailing Address - Phone:314-983-0606
Mailing Address - Fax:314-983-0608
Practice Address - Street 1:763 S NEW BALLAS RD
Practice Address - Street 2:SUITE 220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8704
Practice Address - Country:US
Practice Address - Phone:314-983-0606
Practice Address - Fax:314-983-0608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD101423208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO114721OtherBLUE CROSS BLUE SHIELD
MO5013620OtherAETNA
MO286120OtherHEALTHLINK
MOG10654OtherMERCY HEALTH PLAN
MO1210150OtherUNITED HEALTHCARE
MO214028OtherGROUP HEALTH PLAN
MO286120OtherHEALTHLINK