Healthcare Provider Details

I. General information

NPI: 1104515857
Provider Name (Legal Business Name): MICHAEL C COLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4030 CHOUTEAU AVE
SAINT LOUIS MO
63110-1754
US

IV. Provider business mailing address

1153 E GANNON DR
FESTUS MO
63028-2611
US

V. Phone/Fax

Practice location:
  • Phone: 636-282-0380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number2020033685
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: