Healthcare Provider Details

I. General information

NPI: 1629241039
Provider Name (Legal Business Name): MIDCOUNTY OB GYN GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD STE 250C
SAINT LOUIS MO
63131-2322
US

IV. Provider business mailing address

3009 N BALLAS RD STE 250C
SAINT LOUIS MO
63131-2322
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-9199
  • Fax: 618-939-7539
Mailing address:
  • Phone: 314-567-9199
  • Fax: 618-939-7539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number29126
License Number StateMO

VIII. Authorized Official

Name: DR. IVAN T MYERS
Title or Position: PRESIDENT
Credential:
Phone: 314-567-9199