Healthcare Provider Details

I. General information

NPI: 1922585389
Provider Name (Legal Business Name): METRO MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 10/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 CEDAR PLAZA PKWY STE 300
SAINT LOUIS MO
63128-3891
US

IV. Provider business mailing address

11115 NEW HALLS FERRY RD
FLORISSANT MO
63033-7613
US

V. Phone/Fax

Practice location:
  • Phone: 314-647-9797
  • Fax:
Mailing address:
  • Phone: 314-921-6200
  • Fax: 314-830-0756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR6047
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberR6047
License Number StateMO

VIII. Authorized Official

Name: MR. JAWED H SIDDIQUI
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 314-921-6200