Basic Information
| Provider Information | |||||||||
| NPI: | 1790984904 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST INTERNISTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 N MASON RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149968349 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1040 N MASON RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149968349 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 07/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | DEMETRY | ||||||||
| AuthorizedOfficialFirstName: | KAMAL | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3149968349 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 105483 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.