MEDICARE: THEODORE G. SAMPLE JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	112824	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922191584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODORE G. SAMPLE JR. M.D.

Provider Business Mailing Address
First Line	:	621 S. NEW BALLAS ROAD
Second Line	:	SUITE 6009-B
City	:	ST. LOUIS
State	:	MO
Zip	:	63141
Country	:	US
Telephone Number	:	314-251-6598
Fax Number	:	314-251-7990

Provider Business Practice Location Address
First Line	:	621 S. NEW BALLAS ROAD
Second Line	:	SUITE 6009-B
City	:	ST. LOUIS
State	:	MO
Zip	:	63141
Country	:	US
Telephone Number	:	314-251-6598
Fax Number	:	314-251-7990

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/08/2007

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Directions to “ THEODORE G. SAMPLE JR. M.D.” Practice Location

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