Provider Demographics
NPI:1487807483
Name:COLBERT HEALTHCARE & PREVENTIVE WELLNESS, P.C.
Entity type:Organization
Organization Name:COLBERT HEALTHCARE & PREVENTIVE WELLNESS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-383-5221
Mailing Address - Street 1:7601 NATURAL BRIDGE ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121
Mailing Address - Country:US
Mailing Address - Phone:314-383-5221
Mailing Address - Fax:314-383-5228
Practice Address - Street 1:7601 NATURAL BRIDGE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4904
Practice Address - Country:US
Practice Address - Phone:314-383-5221
Practice Address - Fax:314-383-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8H27261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203628011Medicaid
MOC36353Medicare PIN