Provider Demographics
NPI:1023467008
Name:MID-TOWN MEDICAL PRACTICE, LLC
Entity type:Organization
Organization Name:MID-TOWN MEDICAL PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IQBAL
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-651-6132
Mailing Address - Street 1:424 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1378
Mailing Address - Country:US
Mailing Address - Phone:877-748-7030
Mailing Address - Fax:877-264-9140
Practice Address - Street 1:9 SACKSTON WOODS LN
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-8228
Practice Address - Country:US
Practice Address - Phone:314-651-6132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty