Provider Demographics
NPI:1053472092
Name:MIDWEST OTOLOGIC GROUP, P.C.
Entity Type:Organization
Organization Name:MIDWEST OTOLOGIC GROUP, P.C.
Other - Org Name:PETER G. SMITH, MD, PETER G. SMITH, MD, PHD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:GAILLARD
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:314-432-5151
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 597A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-432-5151
Mailing Address - Fax:314-432-8795
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 597A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-432-5151
Practice Address - Fax:314-432-8795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR8770207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1518961440OtherPERSONAL NPI
0000003435Medicare NSC
A12356Medicare UPIN