=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336216902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DES PERES MEDICAL SPECIALIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2355 DOUGHERTY FERRY RD SUITE 408
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-3325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-821-3111
-----------------------------------------------------
Fax | 314-821-8846
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 790056
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63179-0056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INTERNAL MEDICINE & CRITICAL CARE
-----------------------------------------------------
Name | DR. MICHAEL DAVID IMPEY
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 314-821-3111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | R9B88
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------