MEDICARE: ST MEDICAL INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1477192193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST MEDICAL INSTITUTE

Provider Business Mailing Address
First Line	:	6900 BROCKTON AVE STE 200
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3818
Country	:	US
Telephone Number	:	951-682-6263
Fax Number	:

Provider Business Practice Location Address
First Line	:	4137 MAINE AVE
Second Line	:
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-3309
Country	:	US
Telephone Number	:	480-626-3416
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SAMER SANNOUFI
Credential	:	MD
Telephone Number	:	480-626-3416

Provider Enumeration Date	:	12/27/2019
Last Update Date	:	12/27/2019

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Directions to “ST MEDICAL INSTITUTE ” Practice Location

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