Provider Demographics
NPI:1114964442
Name:ADEM, ANTOINE M (MD)
Entity Type:Individual
Prefix:MR
First Name:ANTOINE
Middle Name:M
Last Name:ADEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 504835
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4835
Mailing Address - Country:US
Mailing Address - Phone:636-931-7101
Mailing Address - Fax:636-933-2383
Practice Address - Street 1:1439 US HIGHWAY 61 STE A
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4154
Practice Address - Country:US
Practice Address - Phone:636-931-7101
Practice Address - Fax:636-933-2383
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111363174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205889926Medicaid
MO507493401Medicaid
MOP00258467OtherRR MEDICARE
MOP00258467OtherRR MEDICARE
MO507493401Medicaid