MEDICARE: DR. BAOLIN FAN MD

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	110986	MO

General Provider Information

NPI Number	:	1568568897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BAOLIN FAN MD

Provider Business Mailing Address
First Line	:	2331 HAMPTON AVENUE
Second Line	:
City	:	ST LOUIS
State	:	MO
Zip	:	63139-2908
Country	:	US
Telephone Number	:	314-772-1441
Fax Number	:	314-772-0600

Provider Business Practice Location Address
First Line	:	2331 HAMPTON AVENUE
Second Line	:
City	:	ST LOUIS
State	:	MO
Zip	:	63139-2908
Country	:	US
Telephone Number	:	314-772-1441
Fax Number	:	314-772-0600

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

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/09/2007

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