Provider Demographics
NPI:1073705737
Name:ST .CLAIR PEDAITRICS, LLC
Entity Type:Organization
Organization Name:ST .CLAIR PEDAITRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:T
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-624-9970
Mailing Address - Street 1:4941 BENCHMARK CENTRE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2038
Mailing Address - Country:US
Mailing Address - Phone:618-624-9970
Mailing Address - Fax:618-624-9973
Practice Address - Street 1:4941 BENCHMARK CENTRE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2038
Practice Address - Country:US
Practice Address - Phone:618-624-9970
Practice Address - Fax:618-624-9973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08223014OtherBLUE CROSS BLUE SHIELD