MEDICARE: DR. SIROTH CHARNOND M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	108377	MO
2	207R00000X	Internal Medicine Physician	036.150546	IL

General Provider Information

NPI Number	:	1265421218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SIROTH CHARNOND M.D.

Provider Business Mailing Address
First Line	:	PO BOX 746715
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6715
Country	:	US
Telephone Number	:	773-352-1515
Fax Number	:	312-929-0373

Provider Business Practice Location Address
First Line	:	7421 S OUTER 364
Second Line	:
City	:	DARDENNE PRAIRIE
State	:	MO
Zip	:	63368-7014
Country	:	US
Telephone Number	:	636-561-8100
Fax Number	:	636-561-3396

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	06/10/2025

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