Provider Demographics
NPI:1104954692
Name:SPECIALTY & PRIMARY CARE LLC
Entity type:Organization
Organization Name:SPECIALTY & PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NAYYER
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-5144
Mailing Address - Street 1:3009 N BALLAS RD
Mailing Address - Street 2:SUITE 229A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2322
Mailing Address - Country:US
Mailing Address - Phone:314-432-5144
Mailing Address - Fax:314-432-2400
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:SUITE 229A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-432-5144
Practice Address - Fax:314-432-2400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109425207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361744184Medicaid
MO208721902Medicaid
MO208721902Medicaid
IL361744184Medicaid
MOG18528Medicare UPIN