Provider Demographics
NPI:1962430157
Name:SPECIALIZED WOUND MANAGEMENT LLC
Entity type:Organization
Organization Name:SPECIALIZED WOUND MANAGEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HARTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-733-7000
Mailing Address - Street 1:14805 N OUTER 40 RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-6060
Mailing Address - Country:US
Mailing Address - Phone:636-733-7000
Mailing Address - Fax:636-733-7010
Practice Address - Street 1:14805 N OUTER 40 RD
Practice Address - Street 2:SUITE 320
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-6060
Practice Address - Country:US
Practice Address - Phone:888-811-4677
Practice Address - Fax:800-605-8906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1084Medicare PIN
IL213122Medicare PIN
MO000013853Medicare PIN
MOS390000Medicare PIN
IL204546Medicare PIN
KSS390000AMedicare PIN
MOMA1087Medicare PIN
IL213123Medicare PIN
IL205298Medicare PIN