Healthcare Provider Details

I. General information

NPI: 1104872381
Provider Name (Legal Business Name): MARK M CHIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 W LIBERTY ST
FARMINGTON MO
63640-1921
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR SUITE 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 573-760-8488
  • Fax: 573-756-3793
Mailing address:
  • Phone: 573-760-8488
  • Fax: 573-756-3793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number36657
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: