Healthcare Provider Details

I. General information

NPI: 1780845834
Provider Name (Legal Business Name): CHILDEBERT ST LOUIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 ROUTE 45 STE 102
NEW CITY NY
10956-1123
US

IV. Provider business mailing address

873 ROUTE 45 STE 102
NEW CITY NY
10956-1123
US

V. Phone/Fax

Practice location:
  • Phone: 845-375-0685
  • Fax: 845-503-2363
Mailing address:
  • Phone: 845-375-0685
  • Fax: 845-503-2363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number65603608
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number250239
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: