Provider Demographics
NPI:1386694651
Name:ELDRIDGE, ALVERNE
Entity type:Individual
Prefix:
First Name:ALVERNE
Middle Name:
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3005
Mailing Address - Country:US
Mailing Address - Phone:314-879-6300
Mailing Address - Fax:314-879-6372
Practice Address - Street 1:8605 TARA LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63147-1331
Practice Address - Country:US
Practice Address - Phone:314-879-6363
Practice Address - Fax:314-879-6372
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO046837363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427748801Medicaid
MOQ37064Medicare UPIN
MO824202931Medicare PIN