Provider Demographics
NPI:1225072671
Name:GATEWAY HOSPITALIST PC
Entity Type:Organization
Organization Name:GATEWAY HOSPITALIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:HAQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-713-3665
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0449
Mailing Address - Country:US
Mailing Address - Phone:314-713-3665
Mailing Address - Fax:
Practice Address - Street 1:4455 DUNCAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1111
Practice Address - Country:US
Practice Address - Phone:314-658-3800
Practice Address - Fax:636-333-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2023-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160353207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507420701Medicaid
MO507420701Medicaid