1508874959 NPI number — DR. LOUIS ST PETERY M.D.

Table of content: SARAH LOWE RBT (NPI 1093387581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508874959 NPI number — DR. LOUIS ST PETERY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST PETERY
Provider First Name:
LOUIS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1508874959
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12427
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32317-2427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-297-0114
Provider Business Mailing Address Fax Number:
850-297-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1132 LEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32303-6508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-224-8833
Provider Business Practice Location Address Fax Number:
850-224-8802
Provider Enumeration Date:
08/03/2006

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: 2080P0202X , with the licence number:  ME17395 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00055118A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 537047001 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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