1972542603 NPI number — PEGGY A PETRALIA D.O.

Table of content: PEGGY A PETRALIA D.O. (NPI 1972542603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972542603 NPI number — PEGGY A PETRALIA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRALIA
Provider First Name:
PEGGY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1972542603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1836 LACKLAND HILL PKWY
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63146-3572
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-989-0300
Provider Business Mailing Address Fax Number:
314-810-1399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6420 CLAYTON RD
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:
63117-1811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-768-8000
Provider Business Practice Location Address Fax Number:
314-768-8011
Provider Enumeration Date:
06/06/2006

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: 207P00000X , with the licence number:  100232 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 100232 , 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: 1972542603 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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