Provider Demographics
NPI:1437250305
Name:ST LOUIS, MICHAEL ROBERT (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:ST LOUIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5507 VANDEMERE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-7282
Mailing Address - Country:US
Mailing Address - Phone:989-832-9124
Mailing Address - Fax:
Practice Address - Street 1:300 SOUTH WARWICK DRIVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801
Practice Address - Country:US
Practice Address - Phone:989-463-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023072363A00000X
NJ25MP00606400363A00000X
OH50.005783RX363A00000X
MI003873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P79742Medicare UPIN
MIN82810001Medicare ID - Type Unspecified