Provider Demographics
NPI:1346471679
Name:OVERLAND MEDICAL GROUP
Entity Type:Organization
Organization Name:OVERLAND MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:LYSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-862-5044
Mailing Address - Street 1:8888 LADUE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-2056
Mailing Address - Country:US
Mailing Address - Phone:314-862-5044
Mailing Address - Fax:
Practice Address - Street 1:8888 LADUE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-2056
Practice Address - Country:US
Practice Address - Phone:314-862-5044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO27304207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty