Provider Demographics
NPI:1457383713
Name:ERNST, EDWIN C III (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:C
Last Name:ERNST
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 EARTH CITY PLAZA EXPRESSWAY
Mailing Address - Street 2:SUITE 121
Mailing Address - City:EARTH CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63045
Mailing Address - Country:US
Mailing Address - Phone:314-770-2133
Mailing Address - Fax:314-770-2154
Practice Address - Street 1:12303 DEPAUL DR
Practice Address - Street 2:DEPAUL HEALTH CENTER
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-344-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2A562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201796604Medicaid
MO201796604Medicaid
A27425Medicare UPIN
MO003010025Medicare ID - Type Unspecified
MO300041142Medicare PIN