Healthcare Provider Details

I. General information

NPI: 1467340380
Provider Name (Legal Business Name): IMPACT PHYSICIAN GROUP NEUROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10018 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

21 EASTBROOK BND STE 218
PEACHTREE CITY GA
30269-1546
US

V. Phone/Fax

Practice location:
  • Phone: 314-208-6000
  • Fax:
Mailing address:
  • Phone: 678-967-5599
  • Fax: 678-519-2831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL MILLER
Title or Position: CEO
Credential: CEO
Phone: 678-967-5599