Provider Demographics
NPI:1194125195
Name:WEST COUNTY INFECTIOUS DISEASE, LLC
Entity type:Organization
Organization Name:WEST COUNTY INFECTIOUS DISEASE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-477-9827
Mailing Address - Street 1:16918 WESTRIDGE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:GROVER
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1127
Mailing Address - Country:US
Mailing Address - Phone:636-566-8155
Mailing Address - Fax:636-566-8732
Practice Address - Street 1:10004 KENNERLY RD STE 392
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:636-489-1602
Practice Address - Fax:636-600-5294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty