Provider First Line Business Practice Location Address: 
615 S NEW BALLAS RD
    Provider Second Line Business Practice Location Address: 
DEPT. OF ANESTHESIOLOGY
    Provider Business Practice Location Address City Name: 
SAINT LOUIS
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
63141-8221
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
636-386-9224
    Provider Business Practice Location Address Fax Number: 
636-386-7679
    Provider Enumeration Date: 
09/09/2014