Provider Demographics
NPI:1922266212
Name:MIDWEST MEDICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:MIDWEST MEDICAL ASSOCIATES, INC
Other - Org Name:SOUTHWEST MEDICAL CENTER - EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:M
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-633-8641
Mailing Address - Street 1:7345 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-4405
Mailing Address - Country:US
Mailing Address - Phone:314-752-7100
Mailing Address - Fax:314-752-3256
Practice Address - Street 1:7331 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-4405
Practice Address - Country:US
Practice Address - Phone:314-752-7100
Practice Address - Fax:314-752-3256
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST MEDICAL ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-23
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO152W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO502461700Medicaid
MOCH3968OtherRR MEDICARE
MOCH3968OtherRR MEDICARE