MEDICARE: MIDWEST BONE & JOINT CENTER, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	207XS0114X	Adult Reconstructive Orthopaedic Surgery Physician	110583	MO

General Provider Information

NPI Number	:	1437297967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST BONE & JOINT CENTER, PC

Provider Business Mailing Address
First Line	:	PO BOX 795057
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63179-0795
Country	:	US
Telephone Number	:	314-989-0300
Fax Number	:

Provider Business Practice Location Address
First Line	:	1517 UNION AVE
Second Line	:	SUITE D
City	:	MOBERLY
State	:	MO
Zip	:	65270-9471
Country	:	US
Telephone Number	:	660-385-1006
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DONET CHRISTOPHER MAIN
Credential	:	DO
Telephone Number	:	660-385-1006

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	09/23/2010

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