Basic Information
| Provider Information | |||||||||
| NPI: | 1053385880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MICHELSON | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS PL | ||||||||
| Address2: | NWT 8328 CB 8116 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144542694 | ||||||||
| FaxNumber: | 3144542515 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CHILDRENS PL STE C | ||||||||
| Address2: | STE C | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144542694 | ||||||||
| FaxNumber: | 3144542515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 01/24/2018 | ||||||||
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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 | 208000000X | 2010028283 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0201X | 2010028283 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology |
ID Information
| ID | Type | State | Issuer | Description | 1053385880 | 05 | MO | MEDICAID | 36092147 | 05 | IL | MEDICAID |