Basic Information
| Provider Information | |||||||||
| NPI: | 1760864888 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETEMADY-DEYLAMY | ||||||||
| FirstName: | ALI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10010 KENNERLY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145251328 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10010 KENNERLY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145251328 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2015 | ||||||||
| LastUpdateDate: | 08/10/2019 | ||||||||
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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 | 207Q00000X | 5101021789 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 2016015544 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2017016664 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.