Healthcare Provider Details

I. General information

NPI: 1013170679
Provider Name (Legal Business Name): MARYLAND MEDICAL GROUP LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S WOODS MILL RD SUITE 350N
CHESTERFIELD MO
63017-3625
US

IV. Provider business mailing address

222 S WOODS MILL RD SUITE 350N
CHESTERFIELD MO
63017-3625
US

V. Phone/Fax

Practice location:
  • Phone: 314-205-6557
  • Fax:
Mailing address:
  • Phone: 314-205-6557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM G BOWEN
Title or Position: PRESIDENT
Credential: MD
Phone: 314-367-3113