Healthcare Provider Details

I. General information

NPI: 1922093632
Provider Name (Legal Business Name): MIA OF ST CHARLES COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 KISKER RD STE 145
SAINT CHARLES MO
63304-8781
US

IV. Provider business mailing address

PO BOX 868
EDWARDSVILLE IL
62025-0868
US

V. Phone/Fax

Practice location:
  • Phone: 636-922-5151
  • Fax: 636-922-5454
Mailing address:
  • Phone: 618-659-1167
  • Fax: 618-659-1197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. STEVEN MICHAEL MCRAE
Title or Position: MANAGING MEMBER
Credential:
Phone: 618-659-1167