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General NPI Number Information
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NPI Number | 1467340380
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Entity Type | Organization
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Legal Business Name | IMPACT PHYSICIAN GROUP NEUROLOGY LLC
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Dates
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Enumeration Date | 06/27/2025
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Last Update Date | 07/28/2025
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Provider Practice Location Address
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Address Line | 10018 KENNERLY RD
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City | SAINT LOUIS
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State | MO
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Zip | 63128-2106
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Country | US
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Telephone | 314-208-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 21 EASTBROOK BND STE 218
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-1546
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Country | US
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Telephone | 678-967-5599
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Fax | 678-519-2831
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Authorized Official
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Title or Position | CEO
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Name | PAUL MILLER
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Credential | CEO
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Telephone | 678-967-5599
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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