Provider Demographics
NPI:1932358421
Name:INTERNAL MEDICINE & GASTROENTEROLOGY LLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE & GASTROENTEROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCCAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-522-1834
Mailing Address - Street 1:PO BOX 21549
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-0549
Mailing Address - Country:US
Mailing Address - Phone:314-522-1834
Mailing Address - Fax:314-522-6149
Practice Address - Street 1:10121 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-2103
Practice Address - Country:US
Practice Address - Phone:314-522-1834
Practice Address - Fax:314-522-6149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6F90302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000002726Medicare PIN