Provider Demographics
NPI:1831268663
Name:SOUTH ST LOUIS ORTHOPEDIC GROUP INC
Entity type:Organization
Organization Name:SOUTH ST LOUIS ORTHOPEDIC GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MIRBAHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-638-8785
Mailing Address - Street 1:9815 MACKENZIE ROAD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123
Mailing Address - Country:US
Mailing Address - Phone:314-638-8785
Mailing Address - Fax:314-638-8788
Practice Address - Street 1:9815 MACKENZIE ROAD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123
Practice Address - Country:US
Practice Address - Phone:314-638-8785
Practice Address - Fax:314-638-8788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501422901Medicaid
MO0167710001Medicare NSC
A11774Medicare UPIN
MO990001453Medicare PIN