Basic Information
| Provider Information | |||||||||
| NPI: | 1730105057 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUETTNER | ||||||||
| FirstName: | PHYLLIS | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4253 CLAYTON AVE | ||||||||
| Address2: | CB 8118 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143625641 | ||||||||
| FaxNumber: | 3143620369 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 S EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143625641 | ||||||||
| FaxNumber: | 3143620369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 10/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | R7P35 | MO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 021010176 | 05 | MO | MEDICAID | 1998117 | 05 | LA | MEDICAID |