Provider Demographics
NPI:1134284078
Name:MACIEJEWSKI, RAYMOND MARK (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:MARK
Last Name:MACIEJEWSKI
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 1:2001 S LINDBERGH BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-3504
Mailing Address - Country:US
Mailing Address - Phone:314-432-3600
Mailing Address - Fax:314-872-7808
Practice Address - Street 1:2001 S LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-3504
Practice Address - Country:US
Practice Address - Phone:314-432-3600
Practice Address - Fax:314-872-7808
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003018929208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209171917Medicaid