MEDICARE: DR. PHILIP ANDRE' ST. RAYMOND MD

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	208800000X	Urology Physician	14335	AZ
2	208800000X	Urology Physician	0101040640	VA

General Provider Information

NPI Number	:	1609971076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP ANDRE' ST. RAYMOND MD

Provider Business Mailing Address
First Line	:	PO BOX 1710
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86405-1710
Country	:	US
Telephone Number	:	928-453-1800
Fax Number	:	928-453-1625

Provider Business Practice Location Address
First Line	:	1720 MESQUITE AVE
Second Line	:	SUITE 100B
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5602
Country	:	US
Telephone Number	:	928-453-1800
Fax Number	:	928-453-1625

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	08/20/2014

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