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General NPI Number Information
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NPI Number | 1609971076
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Entity Type | Individual
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Provider Name | PHILIP ANDRE' ST. RAYMOND MD
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Gender | Male
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 08/20/2014
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Provider Practice Location Address
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Address Line | 1720 MESQUITE AVE SUITE 100B
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5602
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Country | US
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Telephone | 928-453-1800
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Fax | 928-453-1625
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Provider Business Mailing Address
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Address Line | PO BOX 1710
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86405-1710
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Country | US
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Telephone | 928-453-1800
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Fax | 928-453-1625
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 14335
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 0101040640
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License Number State | VA
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