Provider Demographics
NPI:1679750533
Name:MONTEILH, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MONTEILH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13523 BARRETT PARKWAY DR
Mailing Address - Street 2:STE 210
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-3802
Mailing Address - Country:US
Mailing Address - Phone:314-775-2816
Mailing Address - Fax:314-775-2821
Practice Address - Street 1:300 FIRST CAPITOL DR
Practice Address - Street 2:
Practice Address - City:ST. CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301
Practice Address - Country:US
Practice Address - Phone:314-989-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004019752367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO914607908Medicaid
MOP00456099OtherRR MEDICARE
MO837690276Medicare PIN