1003958778 NPI number — MRS. JENNIFER BETH PELIKAN OTR

Table of content: MRS. JENNIFER BETH PELIKAN OTR (NPI 1003958778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003958778 NPI number — MRS. JENNIFER BETH PELIKAN OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELIKAN
Provider First Name:
JENNIFER
Provider Middle Name:
BETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAYER
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
BETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003958778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15955 NEW HALLS FERRY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORISSANT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63031-1227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-953-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5323 VILLE MARIA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZELWOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63042-1143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-770-2234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2007

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: 225X00000X , with the licence number:  004698 , 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)





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