1750378675 NPI number — LARRY PAUL STEWART MD

Table of content: LARRY PAUL STEWART MD (NPI 1750378675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750378675 NPI number — LARRY PAUL STEWART MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEWART
Provider First Name:
LARRY
Provider Middle Name:
PAUL
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:
STEWART
Provider Other First Name:
L
Provider Other Middle Name:
PAUL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1750378675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 BROADVIEW FARM RD
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:
63141-8501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-576-4046
Provider Business Mailing Address Fax Number:
314-576-4046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1408 N KINGSHIGHWAY BLVD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63113-1400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-361-8283
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2005

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: 207W00000X , with the licence number:  R6898 , 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: 201367703 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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