Provider Demographics
NPI:1962690180
Name:NEIDICH, JULIE ANN (MD)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:ANN
Last Name:NEIDICH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-5641
Mailing Address - Fax:314-362-0369
Practice Address - Street 1:4320 FOREST PARK AVE
Practice Address - Street 2:DIV PA, GENOMIC AND MOLECULAR PATHOLOGY, STE 209
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2979
Practice Address - Country:US
Practice Address - Phone:314-362-5641
Practice Address - Fax:314-362-0369
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017022702207ZP0007X
CAG72772207SG0201X, 207SG0202X, 207SG0203X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Yes207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
No207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics
No207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular Genetics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200090687Medicaid