Healthcare Provider Details

I. General information

NPI: 1639176860
Provider Name (Legal Business Name): MARY CAROLYN GAMACHE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: M. CAROLYN GAMACHE M.D.

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N NEW BALLAS RD SUITE 170
SAINT LOUIS MO
63141-6835
US

IV. Provider business mailing address

450 N NEW BALLAS RD SUITE 170
SAINT LOUIS MO
63141-6835
US

V. Phone/Fax

Practice location:
  • Phone: 314-993-6969
  • Fax: 314-993-0792
Mailing address:
  • Phone: 314-993-6969
  • Fax: 314-993-0792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR6H99
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberR6H99
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: