Provider Demographics
NPI:1376552067
Name:MEDWIN PRIMARY CARE L.L.C.
Entity Type:Organization
Organization Name:MEDWIN PRIMARY CARE L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KURMANADHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-878-0163
Mailing Address - Street 1:PO BOX 797052
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-7000
Mailing Address - Country:US
Mailing Address - Phone:636-461-1414
Mailing Address - Fax:
Practice Address - Street 1:3619 RICHARDSON SQUARE DR
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-6022
Practice Address - Country:US
Practice Address - Phone:636-461-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014446Medicare ID - Type Unspecified