Provider Demographics
NPI:1265508600
Name:MID COUNTY OB GYN GROUP, INC
Entity Type:Organization
Organization Name:MID COUNTY OB GYN GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:TALLEY
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-395-3163
Mailing Address - Street 1:11652 STUDT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7025
Mailing Address - Country:US
Mailing Address - Phone:314-395-3163
Mailing Address - Fax:314-991-5447
Practice Address - Street 1:11652 STUDT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7025
Practice Address - Country:US
Practice Address - Phone:314-395-3163
Practice Address - Fax:314-991-5447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207881301Medicaid
MO000008380Medicare PIN
MO207881301Medicaid