Provider Demographics
NPI:1710012729
Name:DES PERES FAMILY MEDICINE
Entity type:Organization
Organization Name:DES PERES FAMILY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DEMETRIOS
Authorized Official - Middle Name:V
Authorized Official - Last Name:POLITIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:314-965-1965
Mailing Address - Street 1:2325 DOUGHERTY FERRY RD SUITE 104
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3356
Mailing Address - Country:US
Mailing Address - Phone:314-965-1965
Mailing Address - Fax:314-965-1700
Practice Address - Street 1:2325 DOUGHERTY FERRY RD SUITE 104
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3356
Practice Address - Country:US
Practice Address - Phone:314-965-1965
Practice Address - Fax:314-965-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9G32207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A25357Medicare UPIN