Basic Information
| Provider Information | |||||||||
| NPI: | 1154687077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYLACK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148511000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1551 WALL ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633033541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366697006 | ||||||||
| FaxNumber: | 6366697008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2012 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036140361 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2018020904 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.