Healthcare Provider Details

I. General information

NPI: 1285228304
Provider Name (Legal Business Name): GATEWAY DIRECT PRIMARY CARE JV LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 LEMAY FERRY RD STE 115
SAINT LOUIS MO
63129-1576
US

IV. Provider business mailing address

1400 WEWATTA ST STE 350
DENVER CO
80202-5553
US

V. Phone/Fax

Practice location:
  • Phone: 866-808-6005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL JOHNSON PATTON
Title or Position: DIRECTOR OF RISK MANAGEMENT
Credential:
Phone: 704-936-5546