MEDICARE: GATEWAY HEALTH CARE INC

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	2084P0800X	Psychiatry Physician	MDR 3819	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21842	OTHER	MO	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1700066370
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATEWAY HEALTH CARE INC

Provider Business Mailing Address
First Line	:	7428 ETHEL AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1608
Country	:	US
Telephone Number	:	314-567-0560
Fax Number	:	314-989-1336

Provider Business Practice Location Address
First Line	:	7428 ETHEL AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1608
Country	:	US
Telephone Number	:	314-567-0560
Fax Number	:	314-989-1336

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WILLIAM WRIGHT CLENDENIN
Credential	:	M.D.
Telephone Number	:	314-567-0560

Provider Enumeration Date	:	11/12/2007
Last Update Date	:	02/08/2008

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Directions to “GATEWAY HEALTH CARE INC ” Practice Location

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