Healthcare Provider Details

I. General information

NPI: 1578511689
Provider Name (Legal Business Name): MICHAEL R. ST JEAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 ROGERS AVE FL 6
FORT SMITH AR
72903-4073
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 479-274-5100
  • Fax: 479-274-5179
Mailing address:
  • Phone: 479-573-3101
  • Fax: 479-573-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberE-21013
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number68165-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: