Provider Demographics
NPI:1609971076
Name:ST. RAYMOND, PHILIP ANDRE' (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ANDRE'
Last Name:ST. RAYMOND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1710
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-1710
Mailing Address - Country:US
Mailing Address - Phone:928-453-1800
Mailing Address - Fax:928-453-1625
Practice Address - Street 1:1720 MESQUITE AVE
Practice Address - Street 2:SUITE 100B
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5602
Practice Address - Country:US
Practice Address - Phone:928-453-1800
Practice Address - Fax:928-453-1625
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14335208800000X
VA0101040640208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
340000141Medicare ID - Type Unspecified
E45214Medicare UPIN