1457361065 NPI number — SAMUEL J ESSMA MD

Table of content: DR. CARL WAYNE HARRIS JR. DO (NPI 1326000548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457361065 NPI number — SAMUEL J ESSMA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESSMA
Provider First Name:
SAMUEL
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1457361065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 WESTPORT PLAZA DRIVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-548-4772
Provider Business Mailing Address Fax Number:
314-548-4748

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MEMORIAL DR
Provider Second Line Business Practice Location Address:
ALTON MEMORIAL HOSPITAL
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002-6722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-463-7415
Provider Business Practice Location Address Fax Number:
314-821-2180
Provider Enumeration Date:
08/08/2006

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: 2085R0202X , with the licence number:  036084761 , 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: 1390 . This is a "MO BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 431725842MID . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 225826 . This is a "HLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2781 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 46033 . This is a "HCARE USA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300066977 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300066982 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: F42701 . This is a "GATEWAY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 136331 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1600001 . This is a "PH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300066972 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0006021895 . This is a "IL BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0360847611 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300066 . This is a "HLT PART" identifier . This identifiers is of the category "OTHER".




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