Healthcare Provider Details

I. General information

NPI: 1811752900
Provider Name (Legal Business Name): MODERN MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5139 MATTIS RD STE 102
SAINT LOUIS MO
63128-2250
US

IV. Provider business mailing address

5139 MATTIS RD STE 102
SAINT LOUIS MO
63128-2250
US

V. Phone/Fax

Practice location:
  • Phone: 314-396-9517
  • Fax:
Mailing address:
  • Phone: 314-396-9517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSE WOLFE
Title or Position: OWNER
Credential:
Phone: 314-396-9517