Provider Demographics
NPI:1114974219
Name:ST. MARIE, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ST. MARIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32945 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-1587
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2420 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4954
Practice Address - Country:US
Practice Address - Phone:440-997-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35064462S207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00220354OtherMEDICARE TRAVELERS RR-GA
OH942460636340OtherCARESOURCE
OH0573937Medicaid
OHD57112Medicare UPIN
OHP00220354OtherMEDICARE TRAVELERS RR-GA