Healthcare Provider Details

I. General information

NPI: 1467688937
Provider Name (Legal Business Name): CHOTCHAI SRISURO, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOWLES AVE SUITE G10
FENTON MO
63026-2387
US

IV. Provider business mailing address

1011 BOWLES AVE SUITE G10
FENTON MO
63026-2387
US

V. Phone/Fax

Practice location:
  • Phone: 636-496-5450
  • Fax: 636-496-4963
Mailing address:
  • Phone: 636-496-5450
  • Fax: 636-496-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number33186
License Number StateMO

VIII. Authorized Official

Name: DR. CHOTCHAI SRISURO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 314-518-3665