Basic Information
| Provider Information | |||||||||
| NPI: | 1154302289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHON | ||||||||
| FirstName: | GERALD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 S SPRING AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149778462 | ||||||||
| FaxNumber: | 3149773370 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149778462 | ||||||||
| FaxNumber: | 3149773370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | R4H74 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000011339 | 01 | MO | ESSENCE | OTHER | 138654 | 01 | MO | HEALTHLINK | OTHER | 0400402 | 01 | MO | UHC | OTHER | 39965 | 01 | MO | GHP | OTHER | 4136351 | 01 | MO | AETNA | OTHER | A12432 | 01 | MO | MERCY | OTHER | 17644 | 01 | MO | BCBS | OTHER |