Basic Information
| Provider Information | |||||||||
| NPI: | 1902812407 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST BONE & JOINT CENTER PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 LACKLAND HILL PKWY | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
| FaxNumber: | 3148101399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1706 PROSPECT DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 635522615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6603851006 | ||||||||
| FaxNumber: | 6603851028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 08/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | MAIN | ||||||||
| AuthorizedOfficialFirstName: | DONET | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6603851006 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207XS0114X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | CK3308 | 01 | MO | RR MEDICARE | OTHER |