Basic Information
| Provider Information | |||||||||
| NPI: | 1114974219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ST. MARIE | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32945 CANTERBURY RD | ||||||||
| Address2: | |||||||||
| City: | AVON LAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440121587 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2420 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ASHTABULA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440044954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409972262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35064462S | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00220354 | 01 | OH | MEDICARE TRAVELERS RR-GA | OTHER | 942460636340 | 01 | OH | CARESOURCE | OTHER | 0573937 | 05 | OH | MEDICAID |