Provider Demographics
NPI:1760953095
Name:WUCA-FENTON PEDIATRICS, LLC
Entity Type:Organization
Organization Name:WUCA-FENTON PEDIATRICS, LLC
Other - Org Name:WUCA - FENTON PEDIATRICS, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR, CREDENTIALING OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:EGHIGIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-273-0770
Mailing Address - Street 1:4240 DUNCAN AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:714 GRAVOIS RD STE 200
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-7723
Practice Address - Country:US
Practice Address - Phone:636-349-5437
Practice Address - Fax:636-349-6663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty