Provider Demographics
NPI:1124098546
Name:CLEARY, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:CLEARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9336 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:226 S WOODS MILL RD
Practice Address - Street 2:SUITE 52 WEST
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3662
Practice Address - Country:US
Practice Address - Phone:314-434-2399
Practice Address - Fax:314-434-5653
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004023908207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO196234OtherBC/BS MISSOURI
MO1124098546Medicaid
MOP01032450OtherRAILROAD MEDICARE
MO207190802Medicaid
MO1124098546Medicaid
MOP01032450OtherRAILROAD MEDICARE
MOI24301Medicare UPIN