1619117942 NPI number — AMBER ELISE OLIPHANT MPT

Table of content: AMBER ELISE OLIPHANT MPT (NPI 1619117942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619117942 NPI number — AMBER ELISE OLIPHANT MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLIPHANT
Provider First Name:
AMBER
Provider Middle Name:
ELISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DANNENMUELLER
Provider Other First Name:
AMBER
Provider Other Middle Name:
ELISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619117942
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2454 W CLAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CHARLES
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63301-2548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-916-4625
Provider Business Mailing Address Fax Number:
636-916-4628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 MEXICO RD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
SAINT PETERS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63376-1666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-939-9540
Provider Business Practice Location Address Fax Number:
636-939-9886
Provider Enumeration Date:
02/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  07525R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 2004035080 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12206763 . This is a "CAQH ID" identifier . This identifiers is of the category "OTHER".




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