Basic Information
| Provider Information | |||||||||
| NPI: | 1245263367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST EMERGENCY DEPARTMENT SPECIALISTS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 955277 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631955277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177884884 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627810001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177883156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | HARVEY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2177883156 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 08432052 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | CK6793 | 01 | IL | RAILROAD MEDICARE | OTHER |