Provider Demographics
NPI:1093235129
Name:JMJ MEDICAL ENTERPRISE, LLC
Entity Type:Organization
Organization Name:JMJ MEDICAL ENTERPRISE, LLC
Other - Org Name:JMJ MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CASINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-283-8950
Mailing Address - Street 1:8790 WATSON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-5140
Mailing Address - Country:US
Mailing Address - Phone:314-774-0300
Mailing Address - Fax:
Practice Address - Street 1:8790 WATSON RD STE 201
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-5140
Practice Address - Country:US
Practice Address - Phone:314-774-0300
Practice Address - Fax:844-600-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-20
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5P40208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty