1528020328 NPI number — JENNIFER L ETLING MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528020328 NPI number — JENNIFER L ETLING MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETLING
Provider First Name:
JENNIFER
Provider Middle Name:
L
Provider Name Prefix Text:
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:
DELAMIELLEURE
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528020328
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 JUNGERMANN CIRCLE
Provider Second Line Business Mailing Address:
STE 205
Provider Business Mailing Address City Name:
ST PETERS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63376
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-441-2122
Provider Business Mailing Address Fax Number:
636-441-5290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 JUNGERMANN CIRCLE
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
ST PETERS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-441-2122
Provider Business Practice Location Address Fax Number:
636-441-5290
Provider Enumeration Date:
04/05/2006

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: 208600000X , with the licence number:  2005000203 , 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: 165817 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 209370105 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: M6725 . This is a "MEDICARE ARKANSAS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 165817 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4309109800 . This is a "PRODENTIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 017283 . This is a "EXCLUSIVE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12593 . This is a "ESSENCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 231210 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00195292 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1700267 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 487573 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7986366 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: H74520 . This is a "MERCY" identifier . This identifiers is of the category "OTHER".




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