Healthcare Provider Details

I. General information

NPI: 1396455150
Provider Name (Legal Business Name): MID WEST CLINICAL PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2022
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15345 SCHOETTLER ESTATES DR
CHESTERFIELD MO
63017-5461
US

IV. Provider business mailing address

15345 SCHOETTLER ESTATES DR
CHESTERFIELD MO
63017-5461
US

V. Phone/Fax

Practice location:
  • Phone: 917-500-3356
  • Fax: 636-778-9569
Mailing address:
  • Phone: 917-500-3356
  • Fax: 636-778-9569

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 Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. MANIRUL TAMAL
Title or Position: OWNER
Credential: MD
Phone: 917-500-3356