Healthcare Provider Details

I. General information

NPI: 1851336630
Provider Name (Legal Business Name): MICHAEL L MITTERMEYER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

7425 FORSYTH BLVD C B 8221
SAINT LOUIS MO
63105-2171
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-6973
  • Fax: 314-362-1185
Mailing address:
  • Phone: 314-362-6973
  • Fax: 314-362-1185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number083884
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: