Provider Demographics
NPI:1639176860
Name:GAMACHE, MARY CAROLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:CAROLYN
Last Name:GAMACHE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:M. CAROLYN
Other - Middle Name:
Other - Last Name:GAMACHE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:450 N NEW BALLAS RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6835
Mailing Address - Country:US
Mailing Address - Phone:314-993-6969
Mailing Address - Fax:314-993-0792
Practice Address - Street 1:450 N NEW BALLAS RD
Practice Address - Street 2:SUITE 170
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6835
Practice Address - Country:US
Practice Address - Phone:314-993-6969
Practice Address - Fax:314-993-0792
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6H99207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203017025Medicaid
MO203017025Medicaid
MOE64648Medicare UPIN