Healthcare Provider Details

I. General information

NPI: 1316089261
Provider Name (Legal Business Name): MICHAEL J HEAVEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 CLAYTON RD SUITE 216
SAINT LOUIS MO
63117-1850
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-1850
US

V. Phone/Fax

Practice location:
  • Phone: 314-646-7848
  • Fax: 314-646-7847
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2009005443
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: