EAR NOSE & THROAT & PLASTIC SURG INC – Facial Plastic Surgery Physician, NPI 1104911288
Facial Plastic Surgery Physician
Main info
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for EAR NOSE & THROAT & PLASTIC SURG INC
2325 DOUGHERTY FERRY RD STE 106
SAINT LOUIS, MO 631223356
Phone: (314) 821-5002
Fax: (314) 821-5029
Type: Mailing
12277 DePaul Dr Ste 303
Bridgeton, MO 630442529
Phone: (314) 821-5002
Fax: (314) 821-8029
Type: Location
4800 Mexico Rd Ste 103
Saint Peters, MO 633761666
Phone: (314) 821-5002
Fax: (314) 821-5029
Type: Location
2315, Dougherty Ferry Road, Des Peres, Saint Louis County, Missouri, 63122, United States
SUITE 103
ST. LOUIS, MO 63122
Phone: (314) 821-5002
Fax: (314) 821-5029
Type: Mailing
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2003-12-06
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Past revalidation due date
Earliest CMS due date was 2025-08-31 (283 days ago).
Enrollment records
1
Earliest due date
2025-08-31
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| O20031206000062 | O | Clinic/Group Practice | MO | 2025-08-31 |
What to do next
- Verify current status on the CMS Revalidation Lookup Tool immediately.
- Complete revalidation in PECOS or contact your Medicare Administrative Contractor (MAC).
- Overdue revalidation can lead to deactivation of Medicare billing privileges.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 63122)
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