Provider Demographics
NPI:1467613125
Name:MRT MEDICAL GROUP.PC
Entity Type:Organization
Organization Name:MRT MEDICAL GROUP.PC
Other - Org Name:COUNTY MEDICAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKATA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-265-3033
Mailing Address - Street 1:PO BOX 411397
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-1397
Mailing Address - Country:US
Mailing Address - Phone:314-265-3033
Mailing Address - Fax:314-821-0952
Practice Address - Street 1:2325 DOUGHERTY FERRY RD,
Practice Address - Street 2:SUITE# 206
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122
Practice Address - Country:US
Practice Address - Phone:314-265-3033
Practice Address - Fax:314-821-0952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000174352207R00000X, 207RG0300X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH31299Medicare UPIN