Basic Information
| Provider Information | |||||||||
| NPI: | 1487601506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST EMERGENCY MANAGEMENT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 797069 | ||||||||
| Address2: | |||||||||
| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631797000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885776337 | ||||||||
| FaxNumber: | 6186243387 | ||||||||
| Practice Location | |||||||||
| Address1: | 1512 N GREEN MOUNT RD | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622691953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186243750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 03/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | GLOVER | ||||||||
| AuthorizedOfficialFirstName: | CARMON | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CMO | ||||||||
| AuthorizedOfficialTelephone: | 8885776337 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 08232205 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | DF2610 | 01 | IL | RAILROAD MEDICARE | OTHER |