Healthcare Provider Details

I. General information

NPI: 1609867134
Provider Name (Legal Business Name): ST PETERS FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 MEXICO ROAD STE #D
ST. PETERS MO
63376-1637
US

IV. Provider business mailing address

5770 MEXICO ROAD STE #D
ST. PETERS MO
63376-1637
US

V. Phone/Fax

Practice location:
  • Phone: 636-926-0558
  • Fax: 636-926-8141
Mailing address:
  • Phone: 636-926-0558
  • Fax: 636-926-8141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TALENA C HUBBARD
Title or Position: OFFICE MANAGER
Credential:
Phone: 636-926-0558