MEDICARE: MEDWIN PRIMARY CARE L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	105197	MO

General Provider Information

NPI Number	:	1376552067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDWIN PRIMARY CARE L.L.C.

Provider Business Mailing Address
First Line	:	PO BOX 797052
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63179-7000
Country	:	US
Telephone Number	:	636-461-1414
Fax Number	:

Provider Business Practice Location Address
First Line	:	3619 RICHARDSON SQUARE DR
Second Line	:
City	:	ARNOLD
State	:	MO
Zip	:	63010-6022
Country	:	US
Telephone Number	:	636-461-1414
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	KURMANADHA GREEN
Credential	:
Telephone Number	:	314-878-0163

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	09/26/2012

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