Provider Demographics
NPI:1811217094
Name:INFERTILITY & GYNECOLOGIC MEDICINE
Entity Type:Organization
Organization Name:INFERTILITY & GYNECOLOGIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:WILBOIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-872-9200
Mailing Address - Street 1:3009 N BALLAS RD
Mailing Address - Street 2:SUITE 359C
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2322
Mailing Address - Country:US
Mailing Address - Phone:314-872-9200
Mailing Address - Fax:314-872-9040
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:SUITE 359C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-872-9200
Practice Address - Fax:314-872-9040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3407174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000008390Medicare UPIN