Provider Demographics
NPI:1053656298
Name:MEREDITH, ALAN MICHAEL (PAC)
Entity type:Individual
Prefix:MR
First Name:ALAN
Middle Name:MICHAEL
Last Name:MEREDITH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:314-364-7586
Mailing Address - Fax:
Practice Address - Street 1:801 HAZELWEST DR
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1754
Practice Address - Country:US
Practice Address - Phone:314-919-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004538363A00000X
MO2024018875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant