Healthcare Provider Details

I. General information

NPI: 1780640037
Provider Name (Legal Business Name): MICHAEL B. GUTWEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD SUITE 130A
SAINT LOUIS MO
63131-2322
US

IV. Provider business mailing address

3009 N BALLAS RD SUITE 130A
SAINT LOUIS MO
63131-2322
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5540
  • Fax:
Mailing address:
  • Phone: 314-996-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberR7058
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: