=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871762385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOCTOR'S CLINICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2008
-----------------------------------------------------
Last Update Date | 05/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12255 DEPAUL DRIVE SUITE 865
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-291-0505
-----------------------------------------------------
Fax | 314-291-0747
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 790379
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63179-0379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-291-0505
-----------------------------------------------------
Fax | 314-291-0747
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT P. POETZ
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 314-291-0505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 152467
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 29351
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------