Provider Demographics
NPI:1417372772
Name:STUART, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:STUART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:618-463-7600
Mailing Address - Fax:618-463-7601
Practice Address - Street 1:4 MEMORIAL DR
Practice Address - Street 2:STE 130B
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6751
Practice Address - Country:US
Practice Address - Phone:618-463-7600
Practice Address - Fax:618-463-7601
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004857363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant