Provider Demographics
NPI:1013431907
Name:TROUT, JAMES EDWARD (35AH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:TROUT
Suffix:
Gender:M
Credentials:35AH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3956 WENZLICK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1254
Mailing Address - Country:US
Mailing Address - Phone:314-799-7711
Mailing Address - Fax:
Practice Address - Street 1:3956 WENZLICK AVE
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109
Practice Address - Country:US
Practice Address - Phone:314-799-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOS9441SCMedicaid