1255320578 NPI number — DR. MENA M LUANGJAMEKORN MD

Table of content: DR. MENA M LUANGJAMEKORN MD (NPI 1255320578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255320578 NPI number — DR. MENA M LUANGJAMEKORN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUANGJAMEKORN
Provider First Name:
MENA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1255320578
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
670 MASON RIDGE CENTER DR
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-8573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-463-7777
Provider Business Mailing Address Fax Number:
618-463-7767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 MEMORIAL DR
Provider Second Line Business Practice Location Address:
STE 230
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002-6751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-463-7777
Provider Business Practice Location Address Fax Number:
618-463-7767
Provider Enumeration Date:
10/19/2005

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: 207Q00000X , with the licence number:  4301076196 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036.125173 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4591430 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: I07388 . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1010621 . This is a "HEALTH ADVANTAGE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4619498 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7450589 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080D410020 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 16492 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080D410020 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1010621 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0802510871 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: I07388 . This is a "HEALTH NET FEDERAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2014164001 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0998002 . This is a "0998002" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0998002 . This is a "GENESEE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4698830 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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