Healthcare Provider Details

I. General information

NPI: 1023592946
Provider Name (Legal Business Name): INSTITUTE OF MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6824 BALSON AVE
SAINT LOUIS MO
63143-2603
US

IV. Provider business mailing address

6824 BALSON AVE
SAINT LOUIS MO
63143-2603
US

V. Phone/Fax

Practice location:
  • Phone: 317-595-0601
  • Fax:
Mailing address:
  • Phone: 317-595-0601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN PATRICK OSHAUGHNESSY
Title or Position: OWNER
Credential:
Phone: 317-595-0601