1598764623 NPI number — DR. JEFFREY T REESE M.D.

Table of content: JODEELIN MINER LMT (NPI 1396199683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598764623 NPI number — DR. JEFFREY T REESE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REESE
Provider First Name:
JEFFREY
Provider Middle Name:
T
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:
1598764623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12855 N FORTY DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-8666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-880-6100
Provider Business Mailing Address Fax Number:
314-997-3248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1390 HIGHWAY 61
Provider Second Line Business Practice Location Address:
SUITE 3300
Provider Business Practice Location Address City Name:
FESTUS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63028-4137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-931-6302
Provider Business Practice Location Address Fax Number:
636-933-3609
Provider Enumeration Date:
07/20/2005

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: 207RC0000X , with the licence number:  101195 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 112975 , 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: 203615521 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203615539 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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