1104021823 NPI number — MARY REBECCA MILLER MSPT

Table of content: MARY REBECCA MILLER MSPT (NPI 1104021823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104021823 NPI number — MARY REBECCA MILLER MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
MARY
Provider Middle Name:
REBECCA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RANDALL
Provider Other First Name:
MARY
Provider Other Middle Name:
REBECCA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104021823
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13537 BARRETT PARKWAY DR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63021-5899
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-821-9126
Provider Business Mailing Address Fax Number:
314-821-9142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 VOGEL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARNOLD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63010-3790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-842-2990
Provider Business Practice Location Address Fax Number:
314-842-5162
Provider Enumeration Date:
06/21/2007

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:  2007000363 , 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)





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