Provider Demographics
NPI:1629134333
Name:THIERAUF, STEPHEN E (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:E
Last Name:THIERAUF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1203 SMIZER MILL RD
Mailing Address - Street 2:STE 108
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3483
Mailing Address - Country:US
Mailing Address - Phone:636-717-1340
Mailing Address - Fax:636-717-1344
Practice Address - Street 1:1203 SMIZER MILL RD
Practice Address - Street 2:STE 108
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-3483
Practice Address - Country:US
Practice Address - Phone:636-717-1340
Practice Address - Fax:636-717-1344
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036109602208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204935407Medicaid
ILH98724Medicare UPIN
ILK02784Medicare ID - Type Unspecified