Provider Demographics
NPI:1033115589
Name:PORTNOY, SHULAMIT MENASHE (MD)
Entity type:Individual
Prefix:
First Name:SHULAMIT
Middle Name:MENASHE
Last Name:PORTNOY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 503900
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-3900
Mailing Address - Country:US
Mailing Address - Phone:314-577-5609
Mailing Address - Fax:314-268-4028
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5609
Practice Address - Fax:314-268-4028
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003001990208000000X, 2080P0006X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208419606Medicaid
MOH86335Medicare UPIN
MO208419606Medicaid