1780998542 NPI number — R. PAUL ST. AMAND, M.D., INC.

Table of content: (NPI 1780998542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780998542 NPI number — R. PAUL ST. AMAND, M.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
R. PAUL ST. AMAND, M.D., 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:
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:
1780998542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4560 ADMIRALTY WAY
Provider Second Line Business Mailing Address:
STE. 355
Provider Business Mailing Address City Name:
MARINA DEL REY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90292-5423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-577-7510
Provider Business Mailing Address Fax Number:
310-821-0664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4560 ADMIRALTY WAY
Provider Second Line Business Practice Location Address:
STE. 355
Provider Business Practice Location Address City Name:
MARINA DEL REY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90292-5423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-577-7510
Provider Business Practice Location Address Fax Number:
310-821-0664
Provider Enumeration Date:
08/03/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ST. AMAND
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-577-7510

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  G2487 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0006G24870 . This is a "BLUECROSS BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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