Active NPI
Justin Ullom
- Athletic Trainer
- Saint Louis, MO
National Provider Identifier
1538626007
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 2020008148
- Practice address
- 1111 Victor St
Saint Louis, MO 63104-4323 - Phone
- (636) 236-5756
- NPI assigned
- Feb 21, 2019
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | |||
| Student in an Organized Health Care Education/Training Program | 390200000X | |||
| Athletic Trainer | 2255A2300X | 2020008148 | MO | Primary |
Addresses
Primary practice location
1111 Victor St
Saint Louis, MO 63104-4323
Mailing address
1911 S 11TH St Apt C
Saint Louis, MO 63104-4089
Phone (636) 236-5756
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2020008148 | MO | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1550707200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1587340800000",
"number": "1538626007",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1911 S 11TH ST APT C",
"city": "SAINT LOUIS",
"state": "MO",
"postal_code": "631044089",
"telephone_number": "636-236-5756"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1111 VICTOR ST",
"city": "SAINT LOUIS",
"state": "MO",
"postal_code": "631044323",
"telephone_number": "636-236-5756"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ULLOM",
"first_name": "JUSTIN",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2019-02-21",
"last_updated": "2020-04-20",
"certification_date": "2020-04-20",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": null,
"license": null,
"primary": false
},
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": false
},
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "MO",
"license": "2020008148",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Saint Louis, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.