Provider Demographics
NPI:1053953422
Name:KIRWOOD MEDICATION ASSISTED TREATMENTS
Entity type:Organization
Organization Name:KIRWOOD MEDICATION ASSISTED TREATMENTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:314-644-8310
Mailing Address - Street 1:111 PROSPECT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6052
Mailing Address - Country:US
Mailing Address - Phone:314-644-8310
Mailing Address - Fax:314-293-6749
Practice Address - Street 1:111 PROSPECT AVE STE 201
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-6052
Practice Address - Country:US
Practice Address - Phone:314-644-8310
Practice Address - Fax:314-293-6749
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR GARY HAMMEN MD PHD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-17
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)