Basic Information
Provider Information | |||||||||
NPI: | 1487690764 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ST JOHN | ||||||||
FirstName: | ELAINE | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 55823 | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352555823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059962244 | ||||||||
FaxNumber: | 2059962254 | ||||||||
Practice Location | |||||||||
Address1: | 525 NHB | ||||||||
Address2: | 619 SOUTH 19TH STREET | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352490001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059962244 | ||||||||
FaxNumber: | 2059962254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 11210 | AL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
ID | Type | State | Issuer | Description | 00114023 | 01 | AL | MISSISSIPPI MEDICAID | OTHER | 4710039 | 01 | AL | UHC | OTHER | 510-17015 | 01 |   | BC BS | OTHER | C76552 | 01 |   | VIVA | OTHER | 00485207X | 01 | AL | GEORGIA MEDICAID | OTHER | 2218 | 01 | AL | HEALTHSPRING | OTHER |