Basic Information
| Provider Information | |||||||||
| NPI: | 1790978252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKOLAJCZAK | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | CHRISTIAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 955534 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631955534 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12266 DE PAUL DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630442514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142182300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2007 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 2009015779 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 2009015779 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
No ID Information.