Provider Demographics
NPI:1477192193
Name:ST MEDICAL INSTITUTE
Entity Type:Organization
Organization Name:ST MEDICAL INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMER
Authorized Official - Middle Name:
Authorized Official - Last Name:SANNOUFI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-626-3416
Mailing Address - Street 1:6900 BROCKTON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3818
Mailing Address - Country:US
Mailing Address - Phone:951-682-6263
Mailing Address - Fax:
Practice Address - Street 1:4137 MAINE AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3309
Practice Address - Country:US
Practice Address - Phone:480-626-3416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care