1104075597 NPI number — DR. NICHOLAS JOHN MAYER D.O.

Table of content: DR. NICHOLAS JOHN MAYER D.O. (NPI 1104075597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104075597 NPI number — DR. NICHOLAS JOHN MAYER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAYER
Provider First Name:
NICHOLAS
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104075597
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11155 DUNN RD STE 211N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63136-6166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-741-1600
Provider Business Mailing Address Fax Number:
314-741-1677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11155 DUNN RD
Provider Second Line Business Practice Location Address:
SUITE 211N
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63136-6150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-741-1600
Provider Business Practice Location Address Fax Number:
314-741-1677
Provider Enumeration Date:
09/10/2008

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: 207RN0300X , with the licence number:  036123985 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: 2004017391 , 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: 1104075597 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300117440001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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