Basic Information
| Provider Information | |||||||||
| NPI: | 1689056111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESMIDT | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1402 S GRAND BLVD RM M260 | ||||||||
| Address2: | ST LOUIS UNIVERSITY SCHOOL OF MEDICINE | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149779852 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3635 VISTA AVE | ||||||||
| Address2: | ST LOUIS UNIVERSITY HOSPITAL | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142687133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2015 | ||||||||
| LastUpdateDate: | 06/20/2015 | ||||||||
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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 | 207P00000X | 2015016412 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.