Healthcare Provider Details

I. General information

NPI: 1578809687
Provider Name (Legal Business Name): MIDWEST MEDICAL SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 CLARKSON CLAYTON CTR #301
ELLISVILLE MO
63011-2145
US

IV. Provider business mailing address

1324 CLARKSON CLAYTON CTR #301
ELLISVILLE MO
63011-2145
US

V. Phone/Fax

Practice location:
  • Phone: 314-735-5015
  • Fax:
Mailing address:
  • Phone: 314-735-5015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberR6G71
License Number StateMO

VIII. Authorized Official

Name: PAUL BURK
Title or Position: PRESIDENT
Credential: D.O.
Phone: 314-735-5015