1790891075 NPI number — MEDICAL WEST PODIATRY LTD MEDICAL WEST BLDG

Table of content: (NPI 1790891075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790891075 NPI number — MEDICAL WEST PODIATRY LTD MEDICAL WEST BLDG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL WEST PODIATRY LTD MEDICAL WEST BLDG
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1790891075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 FRANCIS PL
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
CLAYTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63105-2465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-726-2377
Provider Business Mailing Address Fax Number:
314-726-2397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 FRANCIS PL
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
CLAYTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63105-2465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-726-2377
Provider Business Practice Location Address Fax Number:
314-726-2397
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRANDEL
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
314-726-2377

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1790891075 . This is a "DMERC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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