Healthcare Provider Details

I. General information

NPI: 1104870021
Provider Name (Legal Business Name): MARYLAND MEDICAL GROUP LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 HIGHLANDS PLAZA DRIVE EAST SUITE 375
SAINT LOUIS MO
63110-1340
US

IV. Provider business mailing address

1110 HIGHLANDS PLAZA DR E SUITE 375
SAINT LOUIS MO
63110-1340
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-3113
  • Fax: 314-367-6491
Mailing address:
  • Phone: 314-367-3113
  • Fax: 314-367-6491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM G BOWEN
Title or Position: PRESIDENT
Credential: MD
Phone: 314-367-3113