1477502250 NPI number — DR. JESSE W ST CLAIR III MD

Table of content: DR. JESSE W ST CLAIR III MD (NPI 1477502250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477502250 NPI number — DR. JESSE W ST CLAIR III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST CLAIR
Provider First Name:
JESSE
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
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:
1477502250
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7068
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23707-0068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-686-3516
Provider Business Mailing Address Fax Number:
757-686-0230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1708 OLD DONATION PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23454-3064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-395-5300
Provider Business Practice Location Address Fax Number:
757-213-9341
Provider Enumeration Date:
05/09/2006

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: 207RC0000X , with the licence number:  0101032201 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PAR . This is a "MULTIPLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "FIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1477502250 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 259556 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "VIRGINIA PREMIER HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 890555R , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: PAR . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "VIRGINIA HEALTH NETWORK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: -001 . This is a "TRICARE/CHAMPUS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 35080 . This is a "OPTIMA/SENTARA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "USA MANAGED CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 428960 . This is a "UHC/MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10015738 . This is a "SENTARA OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006055486 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0555R . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 248020 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "CORVEL/CORCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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