Healthcare Provider Details

I. General information

NPI: 1962509992
Provider Name (Legal Business Name): COUNTY CARDIOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD SUITE 247
SAINT LOUIS MO
63128-2141
US

IV. Provider business mailing address

10004 KENNERLY RD SUITE 247
SAINT LOUIS MO
63128-2141
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-5300
  • Fax: 314-849-2014
Mailing address:
  • Phone: 314-849-5300
  • Fax: 314-849-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL H. GIBSON
Title or Position: OWNER, SOLE PROPRIETOR
Credential: M.D.
Phone: 314-849-5300