Provider Demographics
NPI:1841392651
Name:STEWART, JANIECE N (MD)
Entity Type:Individual
Prefix:
First Name:JANIECE
Middle Name:N
Last Name:STEWART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 LACLEDE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2814
Mailing Address - Country:US
Mailing Address - Phone:314-257-0060
Mailing Address - Fax:314-912-0208
Practice Address - Street 1:2 CLUB CENTRE CT STE 3
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3503
Practice Address - Country:US
Practice Address - Phone:314-257-0060
Practice Address - Fax:314-912-0208
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-116659207R00000X, 207RS0010X
MO2019014134207RS0010X
TXU1387207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211965Medicare ID - Type UnspecifiedGROUP NUMBER