1275649048 NPI number — DR. SHERRY X MA MD, PHD

Table of content: DR. SHERRY X MA MD, PHD (NPI 1275649048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275649048 NPI number — DR. SHERRY X MA MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MA
Provider First Name:
SHERRY
Provider Middle Name:
X
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
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:
1275649048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2315 DOUGHERTY FERRY RD
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63122-3383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-984-8380
Provider Business Mailing Address Fax Number:
314-984-5091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2315 DOUGHERTY FERRY RD
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63122-3383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-984-8380
Provider Business Practice Location Address Fax Number:
314-984-5091
Provider Enumeration Date:
08/22/2006

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: 2084N0400X , with the licence number:  106297 , 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: 208715508 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 190661 . This is a "BLUE CROSS AND SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 108428 . This is a "BLUE CROSS AND SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0500157 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 333473 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 5868624 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 218597 . This is a "GROUP HEALTH PLAN ID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 219697 . This is a "GROUP HEALTH PLAN ID NUMB" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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