Provider Demographics
NPI:1700068616
Name:MIDWEST HEART GROUP OF ROLLA, LLC
Entity Type:Organization
Organization Name:MIDWEST HEART GROUP OF ROLLA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:HERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-364-3380
Mailing Address - Street 1:100 W 10TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3248
Mailing Address - Country:US
Mailing Address - Phone:573-426-6751
Mailing Address - Fax:573-426-6752
Practice Address - Street 1:100 W 10TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3248
Practice Address - Country:US
Practice Address - Phone:573-426-6751
Practice Address - Fax:573-426-6752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty