1619020849 NPI number — MARVIN MISHKIN M.D.

Table of content: MARVIN MISHKIN M.D. (NPI 1619020849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619020849 NPI number — MARVIN MISHKIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISHKIN
Provider First Name:
MARVIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619020849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3009 N BALLAS RD
Provider Second Line Business Mailing Address:
SUITE 105B
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63131-2322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-432-2323
Provider Business Mailing Address Fax Number:
314-432-5328

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3009 N BALLAS RD
Provider Second Line Business Practice Location Address:
SUITE 105B
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63131-2322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-432-2323
Provider Business Practice Location Address Fax Number:
314-432-5328
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  R2291 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 18457 . This is a "BCBS OF MO (ANTHEM)" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 43092556563080A001 . This is a "WPS TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2282056002 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4134393 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: A12810 . This is a "MERCY HEALTH PLANS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 090026 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 130817 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2162 . This is a "GROUP HEALTH PLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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