MEDICARE: LONG TERM CARE OF NORTH COUNTY LLC

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

General Provider Information

NPI Number	:	1962915074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONG TERM CARE OF NORTH COUNTY LLC

Provider Business Mailing Address
First Line	:	PO BOX 611
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63032-0611
Country	:	US
Telephone Number	:	314-312-0720
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 PARKER RD
Second Line	:
City	:	BLACK JACK
State	:	MO
Zip	:	63033-4266
Country	:	US
Telephone Number	:	314-312-0720
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARY COLETTE SCHMIDT
Credential	:	MD
Telephone Number	:	314-922-4048

Provider Enumeration Date	:	11/10/2017
Last Update Date	:	12/22/2023

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