1497021034 NPI number — REBECCA L ST. LOUIS DPM

Table of content: REBECCA L ST. LOUIS DPM (NPI 1497021034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497021034 NPI number — REBECCA L ST. LOUIS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST. LOUIS
Provider First Name:
REBECCA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1497021034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W1374 AUBURN ASHFORD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMPBELLSPORT
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53010-3204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-205-9214
Provider Business Mailing Address Fax Number:
847-504-5015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 HUEHL RD
Provider Second Line Business Practice Location Address:
UNIT 13
Provider Business Practice Location Address City Name:
NORTHBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60062-2319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-504-5000
Provider Business Practice Location Address Fax Number:
847-504-5015
Provider Enumeration Date:
03/28/2012

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: 213E00000X , with the licence number:  998 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: 863 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P01333543 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1497021034 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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