1306028261 NPI number — MMA HEALTHCARE OF ST. ELIZABETH, INC.

Table of content: (NPI 1306028261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306028261 NPI number — MMA HEALTHCARE OF ST. ELIZABETH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MMA HEALTHCARE OF ST. ELIZABETH, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1306028261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1869 CRAIG PARK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63146-4122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-543-3800
Provider Business Mailing Address Fax Number:
314-543-3880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
649 S WALNUT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. ELIZABETH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65075-2440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-493-2215
Provider Business Practice Location Address Fax Number:
573-493-2712
Provider Enumeration Date:
12/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUNDOO
Authorized Official First Name:
ASHWIN
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCE
Authorized Official Telephone Number:
314-543-3800

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  034857 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 038104 , 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: 101477305 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com