Healthcare Provider Details

I. General information

NPI: 1649468786
Provider Name (Legal Business Name): MIDWEST CARDIOVASCULAR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 BELLEVUE AVE STE 200
SAINT LOUIS MO
63117-1856
US

IV. Provider business mailing address

1031 BELLEVUE AVE STE 200
SAINT LOUIS MO
63117-1856
US

V. Phone/Fax

Practice location:
  • Phone: 314-644-5650
  • Fax: 314-644-1524
Mailing address:
  • Phone: 314-644-5650
  • Fax: 314-644-1524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR1E18
License Number StateMO

VIII. Authorized Official

Name: MS. NANCY BODET
Title or Position: RN/OFFICE MANAGER
Credential: RN
Phone: 314-644-5650