Provider Demographics
NPI:1497021034
Name:ST. LOUIS, REBECCA L (DPM)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:ST. LOUIS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W1374 AUBURN ASHFORD DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010-3204
Mailing Address - Country:US
Mailing Address - Phone:920-205-9214
Mailing Address - Fax:847-504-5015
Practice Address - Street 1:425 HUEHL RD
Practice Address - Street 2:UNIT 13
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2319
Practice Address - Country:US
Practice Address - Phone:847-504-5000
Practice Address - Fax:847-504-5015
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI998213E00000X
MN863213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01333543OtherRAILROAD MEDICARE
WI1497021034Medicaid
WIK400142566Medicare PIN