Healthcare Provider Details

I. General information

NPI: 1356392674
Provider Name (Legal Business Name): MITCHELL D. BOTNEY, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 NORTH NEW BALLAS ROAD SUITE 256C
ST. LOUIS MO
63131
US

IV. Provider business mailing address

3009 NEW BALLAS ROAD SUITE 256C
ST. LOUIS MO
63131
US

V. Phone/Fax

Practice location:
  • Phone: 314-692-2228
  • Fax:
Mailing address:
  • Phone: 314-692-2228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MITCHELL D. BOTNEY
Title or Position: PRESIDENT
Credential: MD
Phone: 314-692-2228