Healthcare Provider Details

I. General information

NPI: 1700832367
Provider Name (Legal Business Name): MID-COUNTY UROLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 6011B
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD SUITE 6011B
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-569-1750
  • Fax: 314-569-3846
Mailing address:
  • Phone: 314-569-1750
  • Fax: 314-569-3846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number103702
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberR4A96
License Number StateMO

VIII. Authorized Official

Name: LEONARD D GAUM
Title or Position: OWNER PRESIDENT
Credential: MD
Phone: 314-569-1750