Basic Information
| Provider Information | |||||||||
| NPI: | 1730132895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTOOTH | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146479444 | ||||||||
| FaxNumber: | 3146477317 | ||||||||
| Practice Location | |||||||||
| Address1: | 1031 BELLEVUE AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146479444 | ||||||||
| FaxNumber: | 3146477317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 113043 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 205163207 | 05 | MO | MEDICAID | 210862 | 01 | MO | BCBS | OTHER | 0102099 | 01 | MO | UHC | OTHER | 438069 | 01 | MO | HEALTHLINK | OTHER | 290148 | 01 | MO | GHP | OTHER | 752695810MON | 01 | MO | MERCY | OTHER | 000000013907 | 01 | MO | ESSENCE | OTHER |