Healthcare Provider Details

I. General information

NPI: 1821153636
Provider Name (Legal Business Name): MID-WEST PODIATRY & ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11709 OLD BALLAS RD SUITE 201
CREVE COEUR MO
63141-7029
US

IV. Provider business mailing address

11709 OLD BALLAS RD SUITE 201
CREVE COEUR MO
63141-7029
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-1903
  • Fax: 314-432-5105
Mailing address:
  • Phone: 314-432-1903
  • Fax: 314-432-5105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: SANDY PIKE
Title or Position: ADMINISTRATOR
Credential:
Phone: 314-432-1903