Provider Demographics
NPI:1831382431
Name:DAVIS, A. JILL (MD)
Entity type:Individual
Prefix:
First Name:A. JILL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:JILL
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:801 HAZELWEST DR
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1754
Mailing Address - Country:US
Mailing Address - Phone:314-919-2700
Mailing Address - Fax:
Practice Address - Street 1:801 HAZELWEST DR
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1754
Practice Address - Country:US
Practice Address - Phone:314-919-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008007440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1831382431Medicaid
MOP01128467OtherRAILROAD MEDICARE
NY02908107Medicaid
NYRB6133Medicare PIN
MO152800127Medicare PIN
MOP01128467OtherRAILROAD MEDICARE
NYP00623057Medicare PIN