Basic Information
| Provider Information | |||||||||
| NPI: | 1033422480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDARIS | ||||||||
| FirstName: | ABRAHAM | ||||||||
| MiddleName: | BLAIN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10004 KENNERLY RD | ||||||||
| Address2: | STE 364B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145254429 | ||||||||
| FaxNumber: | 3145257260 | ||||||||
| Practice Location | |||||||||
| Address1: | 10004 KENNERLY RD | ||||||||
| Address2: | STE 364B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145254429 | ||||||||
| FaxNumber: | 3145257260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2010 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 6369 | NE | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 2014008997 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.