Provider Demographics
NPI:1184755118
Name:GEROMED, LLC
Entity type:Organization
Organization Name:GEROMED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:THIEN
Authorized Official - Last Name:TANG
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:314-752-8600
Mailing Address - Street 1:4675 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111-1462
Mailing Address - Country:US
Mailing Address - Phone:314-752-8600
Mailing Address - Fax:314-752-8601
Practice Address - Street 1:4675 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-1462
Practice Address - Country:US
Practice Address - Phone:314-752-8600
Practice Address - Fax:314-752-8601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208442400Medicaid
MO508753001Medicaid
MO208393702Medicaid
1023026804OtherPROVIDER NPI
1417040114OtherPROVIDER NPI
MO208393702Medicaid
I11532Medicare UPIN
MO000014235Medicare ID - Type Unspecified