Healthcare Provider Details

I. General information

NPI: 1578927307
Provider Name (Legal Business Name): PHAN SALIGRAMA MD/PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15945 CLAYTON RD STE 120B
BALLWIN MO
63011-2490
US

IV. Provider business mailing address

15945 CLAYTON RD STE 120B
BALLWIN MO
63011-2490
US

V. Phone/Fax

Practice location:
  • Phone: 636-256-5070
  • Fax: 636-256-5066
Mailing address:
  • Phone: 636-256-5070
  • Fax: 636-256-5066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR75476
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number2024015235
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: