Provider Demographics
NPI:1356449144
Name:SAINT-LOUIS, IMMACULA (MD)
Entity Type:Individual
Prefix:
First Name:IMMACULA
Middle Name:
Last Name:SAINT-LOUIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 GREEN ST E
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4105
Mailing Address - Country:US
Mailing Address - Phone:252-243-9800
Mailing Address - Fax:252-243-9888
Practice Address - Street 1:303 GREEN ST E
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4105
Practice Address - Country:US
Practice Address - Phone:252-243-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01289207QA0401X, 208000000X
MA151877208000000X
MDD0088037208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3196209Medicaid
MAA30017Medicare ID - Type Unspecified
MA3196209Medicaid