Basic Information
| Provider Information | |||||||||
| NPI: | 1770691685 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLATH | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 S WOODS MILL RD | ||||||||
| Address2: | STE 309E | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144346130 | ||||||||
| FaxNumber: | 3144341277 | ||||||||
| Practice Location | |||||||||
| Address1: | 11155 DUNN RD | ||||||||
| Address2: | STE 309E | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147419010 | ||||||||
| FaxNumber: | 3147415102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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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 | 208800000X | 33593 | MO | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.