Healthcare Provider Details

I. General information

NPI: 1114974219
Provider Name (Legal Business Name): MICHAEL ST. MARIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 LAKE AVE
ASHTABULA OH
44004-4954
US

IV. Provider business mailing address

32945 CANTERBURY RD
AVON LAKE OH
44012-1587
US

V. Phone/Fax

Practice location:
  • Phone: 440-997-2262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35064462S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: