Healthcare Provider Details

I. General information

NPI: 1144859950
Provider Name (Legal Business Name): AUDRA MARIE ST JOHN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUDRA MARIE ROUGRAFF MD

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 RILEY HOSPITAL DR
INDIANAPOLIS IN
46202-5272
US

IV. Provider business mailing address

PO BOX 719094
CHICAGO IL
60677-9318
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-3774
  • Fax: 317-944-8521
Mailing address:
  • Phone: 317-777-6435
  • Fax: 317-777-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number01089400A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: