Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 14966 | MO |
Y | 213EG0000X | General Practice | 14966 | MO |
NPI | 1003920174 |
---|---|
Provider Name | Dr. Michael Edlin JR. |
First Address | St. Louis, MO 63105 |
Second Address | Saint Louis, MO 63105-3515 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2006 |
Last Update Date | 08/07/2007 |