Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 2010028283 | MO |
Y | 2080P0201X | Pediatric Allergist | 2010028283 | MO |
NPI | 1053385880 |
---|---|
Provider Name | Dr. Peter H Michelson |
First Address | Saint Louis, MO 63110-1002 |
Second Address | Saint Louis, MO 63110-1002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/02/2006 |
Last Update Date | 24/01/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1053385880 | (05) | MO |
36092147 | (05) | IL |