1194754812 NPI number — MRS. JODI MARAM P.T.

Table of content: MRS. JODI MARAM P.T. (NPI 1194754812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194754812 NPI number — MRS. JODI MARAM P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARAM
Provider First Name:
JODI
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOLDFAIN
Provider Other First Name:
JODI
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194754812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 S NEW BALLAS RD
Provider Second Line Business Mailing Address:
SUITE 116E
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-8705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-985-3002
Provider Business Mailing Address Fax Number:
314-985-3012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10435 CLAYTON RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
FRONTENAC
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63131-2909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-985-3002
Provider Business Practice Location Address Fax Number:
314-985-3012
Provider Enumeration Date:
07/03/2006

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: 2251X0800X , with the licence number:  118373 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251X0800X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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