Basic Information
| Provider Information | |||||||||
| NPI: | 1750581666 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RETINA ASSOCIATES OF ST LOUIS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1224 GRAHAM RD | ||||||||
| Address2: | SUITE 3011 | ||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630318028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148391211 | ||||||||
| FaxNumber: | 3148398429 | ||||||||
| Practice Location | |||||||||
| Address1: | 1224 GRAHAM RD | ||||||||
| Address2: | SUITE 3011 | ||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630318028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148931211 | ||||||||
| FaxNumber: | 3148398429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | KLEEKAMP | ||||||||
| AuthorizedOfficialFirstName: | SHERRIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3148391211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0107X | Y | 193400000X SINGLE SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | C17353 | 01 | MO | RAILROAD MEDICARE | OTHER | 502634801 | 05 | MO | MEDICAID |