1316912892 NPI number — MRS. MATTIE WHITE MD

Table of content: MRS. MATTIE WHITE MD (NPI 1316912892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316912892 NPI number — MRS. MATTIE WHITE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
MATTIE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1316912892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3197 PORTIS AVE
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:
63116-2023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3197 PORTIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63116-2023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-713-3847
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2006

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: 207Q00000X , with the licence number:  2008014947 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 036103546 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1316912892 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: CB3700 . This is a "RAILROAD GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 659580 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00189155 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: K04489 . This is a "UMWA PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 10007459 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036103546 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 460661 . This is a "HEALTHLINK PROV NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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