Healthcare Provider Details

I. General information

NPI: 1023061926
Provider Name (Legal Business Name): MICHAEL T RAILEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6125 CLAYTON AVE STE 222
SAINT LOUIS MO
63139-3265
US

IV. Provider business mailing address

6125 CLAYTON AVE STE 222
SAINT LOUIS MO
63139-3265
US

V. Phone/Fax

Practice location:
  • Phone: 314-768-3685
  • Fax: 314-768-3940
Mailing address:
  • Phone: 314-768-3204
  • Fax: 314-768-3940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9336
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: