Provider Demographics
NPI:1447361100
Name:DALY, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DALY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:573-815-2236
Mailing Address - Fax:573-815-2232
Practice Address - Street 1:1605 E BROADWAY
Practice Address - Street 2:SUITE 110
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8023
Practice Address - Country:US
Practice Address - Phone:573-815-2236
Practice Address - Fax:573-815-2232
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33542207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240220228Medicaid
MO240220228Medicaid
MO001013621Medicare ID - Type Unspecified