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General NPI Number Information
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NPI Number | 1922093632
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Entity Type | Organization
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Legal Business Name | MIA OF ST CHARLES COUNTY LLC
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Dates
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Enumeration Date | 09/19/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1475 KISKER RD STE 145
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City | SAINT CHARLES
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State | MO
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Zip | 63304-8781
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Country | US
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Telephone | 636-922-5151
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Fax | 636-922-5454
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Provider Business Mailing Address
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Address Line | PO BOX 868
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-0868
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Country | US
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Telephone | 618-659-1167
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Fax | 618-659-1197
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. STEVEN MICHAEL MCRAE
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Credential |
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Telephone | 618-659-1167
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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