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General NPI Number Information
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NPI Number | 1437372364
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Entity Type | Organization
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Legal Business Name | MERAMEC VALLEY OBGYN INC
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 02/26/2008
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Provider Practice Location Address
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Address Line | 408 GRAVOIS RD
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City | FENTON
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State | MO
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Zip | 63026
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Country | US
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Telephone | 636-343-1144
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Fax | 636-343-6624
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Provider Business Mailing Address
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Address Line | PO BOX 824
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City | FENTON
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State | MO
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Zip | 63026
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Country | US
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Telephone | 636-343-1144
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Fax | 636-343-6624
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | DR. JACK E RICKETTS
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Credential | MD
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Telephone | 636-343-1144
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | R5C65
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License Number State | MO
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