Basic Information
| Provider Information | |||||||||
| NPI: | 1275584419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOSEPH NEUROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 FAR WEST DR | ||||||||
| Address2: | STE 203 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163643834 | ||||||||
| FaxNumber: | 8163643894 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 FAR WEST DR | ||||||||
| Address2: | STE 203 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163643834 | ||||||||
| FaxNumber: | 8163643894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAKOS | ||||||||
| AuthorizedOfficialFirstName: | MIGNON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8163643834 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | R2F40 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.