=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689032708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME DOCTORS MEDICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2016
-----------------------------------------------------
Last Update Date | 02/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1034 S BRENTWOOD BLVD SUITE 450
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63117-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-780-9988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4977 MOUNT ROYAL RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-780-9988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER/OWNER
-----------------------------------------------------
Name | TAMERA JAVIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-780-9988
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------