Provider Demographics
NPI:1215941166
Name:GREDITZER, HARRY GLYN JR (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:GLYN
Last Name:GREDITZER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 DEER TRACKS TRAIL
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-821-5600
Mailing Address - Fax:314-821-2180
Practice Address - Street 1:11133 DUNN ROAD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136
Practice Address - Country:US
Practice Address - Phone:314-653-4300
Practice Address - Fax:314-821-2180
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR78012085R0202X
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
100265OtherH LINK
1077061OtherMC MCAID
A27719OtherGATE WAY
22730OtherBLUE CHOICE
317617OtherHLT PART
1611000OtherPH PLAN
0006021895OtherIL BLUE
1390OtherMO BLUE
2781OtherGHP
6006OtherHCARE USA
L40182OtherIL CARE
2781OtherGHP