Provider Demographics
NPI:1063571016
Name:GERDINE, MICHAEL L (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:GERDINE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 LACLEDE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2814
Mailing Address - Country:US
Mailing Address - Phone:314-361-4650
Mailing Address - Fax:314-361-4663
Practice Address - Street 1:4255 LACLEDE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2814
Practice Address - Country:US
Practice Address - Phone:314-361-4650
Practice Address - Fax:314-361-4663
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000149199111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000025943Medicare ID - Type UnspecifiedPROVIDER ID NUMBER