Basic Information
Provider Information
NPI: 1629035886
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CRAVER
FirstName: JEFFREY
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: CRAVER
OtherFirstName: JEFFREY
OtherMiddleName: L
OtherNamePrefix: DR.
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 2
Mailing Information
Address1: 1402 S GRAND BLVD
Address2:  
City: SAINT LOUIS
State: MO
PostalCode: 631041004
CountryCode: US
TelephoneNumber: 3147688803
FaxNumber: 3149777615
Practice Location
Address1: 1402 S GRAND BLVD
Address2:  
City: SAINT LOUIS
State: MO
PostalCode: 631041004
CountryCode: US
TelephoneNumber: 3147688803
FaxNumber: 3149777615
Other Information
ProviderEnumerationDate: 04/28/2006
LastUpdateDate: 02/04/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/04/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207ZP0102X036-060815ILN Allopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
207ZP0102XR5A28MOY Allopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology

No ID Information.


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