Provider Demographics
NPI:1457867590
Name:EDP OF MISSOURI PC
Entity Type:Organization
Organization Name:EDP OF MISSOURI PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARIBAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-736-8963
Mailing Address - Street 1:141 W JACKSON BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3048
Mailing Address - Country:US
Mailing Address - Phone:312-937-3619
Mailing Address - Fax:
Practice Address - Street 1:677 N NEW BALLAS RD STE 207
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6732
Practice Address - Country:US
Practice Address - Phone:314-569-3141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-27
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental