Provider Demographics
NPI:1356392674
Name:MITCHELL D. BOTNEY, MD
Entity type:Organization
Organization Name:MITCHELL D. BOTNEY, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-692-2228
Mailing Address - Street 1:3009 NEW BALLAS ROAD
Mailing Address - Street 2:SUITE 256C
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-692-2228
Mailing Address - Fax:
Practice Address - Street 1:3009 NORTH NEW BALLAS ROAD
Practice Address - Street 2:SUITE 256C
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-692-2228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202402947Medicaid
MODE8921OtherRAILROAD MEDICARE
MO000014930Medicare PIN