1891216123 NPI number — DR. ELIZABETH ANN SUBA AU.D., CCC-A

Table of content: DR. ELIZABETH ANN SUBA AU.D., CCC-A (NPI 1891216123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891216123 NPI number — DR. ELIZABETH ANN SUBA AU.D., CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUBA
Provider First Name:
ELIZABETH
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D., CCC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOEDEKER
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1891216123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1003 N CASTELLO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORISSANT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63031-4529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-915-6724
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3660 VISTA AVE STE 312
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:
63110-2540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-977-5110
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2017

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: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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