Basic Information
| Provider Information | |||||||||
| NPI: | 1598781718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYCKATYN | ||||||||
| FirstName: | TERENCE | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | MSC 8238-43-1150 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627388 | ||||||||
| FaxNumber: | 3143670225 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 N MASON RD | ||||||||
| Address2: | DIV SURG PLASTICS, MOB 3 STE 110 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627388 | ||||||||
| FaxNumber: | 3143670225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2082S0099X | 2000173749 | MO | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck | 2086S0105X | 2000173749 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | 2086S0122X | 2000173749 | MO | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 207820606 | 05 | MO | MEDICAID |