Provider Demographics
NPI:1639486798
Name:A J SQUITIERI MD PC
Entity Type:Organization
Organization Name:A J SQUITIERI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:A
Authorized Official - Middle Name:J
Authorized Official - Last Name:SQUITIERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-353-5540
Mailing Address - Street 1:5213 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-3170
Mailing Address - Country:US
Mailing Address - Phone:314-353-5540
Mailing Address - Fax:314-353-2433
Practice Address - Street 1:5213 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-3170
Practice Address - Country:US
Practice Address - Phone:314-353-5540
Practice Address - Fax:314-353-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO28648261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200863215Medicaid
MOA13214Medicare UPIN