Basic Information
| Provider Information | |||||||||
| NPI: | 1366413429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST VASCULAR & GENERAL SURGERY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3023 N BALLAS RD | ||||||||
| Address2: | SUITE 210D | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
| FaxNumber: | 3145697135 | ||||||||
| Practice Location | |||||||||
| Address1: | 3023 N BALLAS RD | ||||||||
| Address2: | SUITE 210D | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149939229 | ||||||||
| FaxNumber: | 3149938398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 11/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | RAO | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3149939229 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | R3J01 | MO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 103467 | MO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.