Basic Information
| Provider Information | |||||||||
| NPI: | 1144213265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WADSWORTH | ||||||||
| FirstName: | HARRY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 NANTUCKET LN | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631324137 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3009 N BALLAS RD | ||||||||
| Address2: | SUITE 100B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144321111 | ||||||||
| FaxNumber: | 3144326308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 01/08/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | R7P48 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 24916 | 01 | MO | BC/BS | OTHER | 148998 | 01 | MO | HEALTHLINK | OTHER | 47310 | 01 | MO | GHP | OTHER | 110054267 | 01 | MO | RR MEDICARE | OTHER |