Basic Information
Provider Information | |||||||||
NPI: | 1881741825 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WU-EVANS | ||||||||
FirstName: | EILEEN | ||||||||
MiddleName: | AI-LING | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1430 OLIVE ST | ||||||||
Address2: | SUITE 400 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631032303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3142063700 | ||||||||
FaxNumber: | 3142063708 | ||||||||
Practice Location | |||||||||
Address1: | 3165 MCKELVEY RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | BRIDGETON | ||||||||
State: | MO | ||||||||
PostalCode: | 630442550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3142063900 | ||||||||
FaxNumber: | 3142063992 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 2003004257 | MO | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 000091459 | 05 | MO |   | MEDICAID | BW8348888 | 01 | MO | DEA | OTHER |