Provider Demographics
NPI:1700832367
Name:MID-COUNTY UROLOGY INC
Entity Type:Organization
Organization Name:MID-COUNTY UROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:GAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-569-1750
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 6011B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-569-1750
Mailing Address - Fax:314-569-3846
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 6011B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-569-1750
Practice Address - Fax:314-569-3846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4A96208800000X
MO103702208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201244514Medicaid
H03039Medicare UPIN
MOR4A96Medicare ID - Type Unspecified
MO002014639Medicare ID - Type Unspecified
A10041Medicare UPIN