Provider Demographics
NPI:1750581666
Name:RETINA ASSOCIATES OF ST LOUIS, INC
Entity type:Organization
Organization Name:RETINA ASSOCIATES OF ST LOUIS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEEKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-839-1211
Mailing Address - Street 1:1224 GRAHAM RD
Mailing Address - Street 2:SUITE 3011
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-8028
Mailing Address - Country:US
Mailing Address - Phone:314-839-1211
Mailing Address - Fax:314-839-8429
Practice Address - Street 1:1224 GRAHAM RD
Practice Address - Street 2:SUITE 3011
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8028
Practice Address - Country:US
Practice Address - Phone:314-893-1211
Practice Address - Fax:314-839-8429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC17353OtherRAILROAD MEDICARE
MO502634801Medicaid
MOC17353OtherRAILROAD MEDICARE
MOF20163Medicare UPIN
MO000013412Medicare PIN