Basic Information
| Provider Information | |||||||||
| NPI: | 1457628935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | TIMOTHY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 SAVANNAH RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633032918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362440704 | ||||||||
| FaxNumber: | 6362440704 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 SAVANNAH RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633032918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362440704 | ||||||||
| FaxNumber: | 6362440704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 084580 | MO | Y | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.