Provider Demographics
NPI:1972563799
Name:ST LOUIS, PHILLIP G (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:G
Last Name:ST LOUIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1856
Mailing Address - Country:US
Mailing Address - Phone:407-898-8644
Mailing Address - Fax:407-898-8646
Practice Address - Street 1:532 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1856
Practice Address - Country:US
Practice Address - Phone:407-898-8644
Practice Address - Fax:407-898-8646
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068157100Medicaid
FL6371960001Medicare NSC
FL47579YMedicare PIN
FLD55108Medicare UPIN