Basic Information
| Provider Information | |||||||||
| NPI: | 1518963859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAVIN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6420 CLAYTON RD STE 290 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147818605 | ||||||||
| FaxNumber: | 3147812840 | ||||||||
| Practice Location | |||||||||
| Address1: | 1031 BELLEVUE AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149777455 | ||||||||
| FaxNumber: | 3149777343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 2000157500 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1518963859 | 01 | MO | NPI | OTHER | 205054802 | 05 | MO | MEDICAID |