Provider Demographics
NPI:1629096359
Name:WALTER, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WALTER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:999 EXECUTIVE PARKWAY DR
Mailing Address - Street 2:STE 210
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6336
Mailing Address - Country:US
Mailing Address - Phone:314-514-6000
Mailing Address - Fax:314-514-6020
Practice Address - Street 1:12303 DEPAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-344-6000
Practice Address - Fax:314-514-6020
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-02-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO103849207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208882001Medicaid
290009839Medicare PIN
G52924Medicare UPIN
833610183Medicare PIN