Provider Demographics
NPI:1710925383
Name:STELLA MARIS INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:STELLA MARIS INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:HANI
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:SOUDAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:314-205-1926
Mailing Address - Street 1:12855 N 40 DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8635
Mailing Address - Country:US
Mailing Address - Phone:314-205-1926
Mailing Address - Fax:314-205-1076
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:SUITE 350
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8635
Practice Address - Country:US
Practice Address - Phone:314-205-1926
Practice Address - Fax:314-205-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG29059Medicare UPIN