Provider Demographics
NPI:1952440703
Name:PHON, GILBERT L (AUD, FAAA)
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:L
Last Name:PHON
Suffix:
Gender:M
Credentials:AUD, FAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 N CLOVERLEAF DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-6436
Mailing Address - Country:US
Mailing Address - Phone:636-441-7470
Mailing Address - Fax:636-441-4270
Practice Address - Street 1:4200 N CLOVERLEAF DR
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-6436
Practice Address - Country:US
Practice Address - Phone:636-441-7470
Practice Address - Fax:636-441-4270
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO684231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO192715OtherBLUE CROSS BLUE SHIELD
MO00000002201OtherMERCY PREMIER