1073588000 NPI number — SAMUEL K ST CLAIR MD

Table of content: SAMUEL K ST CLAIR MD (NPI 1073588000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073588000 NPI number — SAMUEL K ST CLAIR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST CLAIR
Provider First Name:
SAMUEL
Provider Middle Name:
K
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:
1073588000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4201 LAKE BOONE TRL
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27607-7512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-235-0500
Provider Business Mailing Address Fax Number:
919-235-0505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4207 LAKE BOONE TRL STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27607-6685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-784-1410
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2006

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: 207T00000X , with the licence number:  39097 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 56219447701 . This is a "TRICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8979535 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 97486 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 706943 . This is a "CHOICE CARE NETWORK" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 79535 . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2070150 . This is a "FIRST HEALTH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0650385 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4063806 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 140006908 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com