Provider Demographics
NPI:1467450023
Name:CALDWELL GENERAL PRACTICE, INC.
Entity Type:Organization
Organization Name:CALDWELL GENERAL PRACTICE, INC.
Other - Org Name:GENERAL PRACTICE INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:REYNAL
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:314-521-7768
Mailing Address - Street 1:2880 NETHERTON DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136
Mailing Address - Country:US
Mailing Address - Phone:314-521-7768
Mailing Address - Fax:314-838-3683
Practice Address - Street 1:2880 NETHERTON DR
Practice Address - Street 2:SUITE 103
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136
Practice Address - Country:US
Practice Address - Phone:314-521-7768
Practice Address - Fax:314-838-3683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5E11207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242386712Medicaid
MO242386712Medicaid
000002199Medicare PIN