Provider Demographics
NPI:1952715005
Name:M. EDWARD MIMLITZ PC
Entity Type:Organization
Organization Name:M. EDWARD MIMLITZ PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MIMLITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-432-8505
Mailing Address - Street 1:621 S. NEW BALLAS RD.
Mailing Address - Street 2:SUITE 419-A
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8259
Mailing Address - Country:US
Mailing Address - Phone:314-432-8505
Mailing Address - Fax:314-432-6853
Practice Address - Street 1:621 S. NEW BALLAS RD.
Practice Address - Street 2:SUITE 419-A
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8259
Practice Address - Country:US
Practice Address - Phone:314-432-8505
Practice Address - Fax:314-432-6853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101836207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208179317Medicaid
MO0700441OtherUNITED HEALTH CARE
MO0700441OtherUNITED HEALTH CARE