Provider Demographics
NPI:1043407521
Name:COUNTY INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:COUNTY INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLIANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-628-9994
Mailing Address - Street 1:224 S WOODS MILL RD
Mailing Address - Street 2:SUITE 370 SOUTH
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3451
Mailing Address - Country:US
Mailing Address - Phone:314-628-9994
Mailing Address - Fax:
Practice Address - Street 1:224 S WOODS MILL RD
Practice Address - Street 2:SUITE 370 SOUTH
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3625
Practice Address - Country:US
Practice Address - Phone:314-628-9994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG67034Medicare UPIN