Provider Demographics
NPI:1467645036
Name:ALTA PREMIER HEALTH SERVICES INC
Entity Type:Organization
Organization Name:ALTA PREMIER HEALTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ALPHONSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUBOEUF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-361-0477
Mailing Address - Street 1:625 NORTH EUCLID AVENUE
Mailing Address - Street 2:SUITE 214
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1660
Mailing Address - Country:US
Mailing Address - Phone:314-361-0477
Mailing Address - Fax:314-361-3771
Practice Address - Street 1:625 NORTH EUCLID AVENUE
Practice Address - Street 2:SUITE 214
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-1660
Practice Address - Country:US
Practice Address - Phone:314-361-0477
Practice Address - Fax:314-361-3771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507381309Medicaid
MO507381309Medicaid